This document provides information on female sterilization as a method of contraception. It discusses the surgical procedure of cutting or blocking the fallopian tubes to prevent pregnancy permanently. Some key points covered include that sterilization is a very effective method with a low failure rate but is also a surgical procedure that carries risks of pain, infection and other complications. The document outlines when sterilization can be performed and considerations around a client's health and ability to provide informed consent. Steps of the procedure and post-operative care are described.

1. Dr. Meenakshi Sharma
MD (AIIMS), FICMCH
Specialist Obs & Gyn
Dr Hedgewar Arogya Sansthan
2012

2.  Surgical procedure- cutting, sealing
or blocking the fallopian tubes
 Prevents fertilization of oocytes and
its transport to uterus
 Permanent

3.  Bluedell, 1823- 1st
suggested as method of
ligation
 Madlender 1919, Irving in 1924, Pomeroy in
1930,
 Uchida in 1940 published various methods.
 Bosch in 1936- Ist lap ligation in Switzerland, by
electo coagulation
 In Nov 2002, FDA approved Essure micro
inserts for hysteroscopic procedures.

4. NUR 352GYNAECOLOGY NURSING 4

5.  Very effective- Low failure rate- 0.1-0.5% (first
year), 1.8% in 10 yrs
 Permanent
 A single procedure leads to lifelong, safe and very
effective family planning.
 Nothing to remember, no supplies needed and no
repeated clinic visits required.
 No interference with sex. Does not affect a
woman’s ability to have sex.
 No known long-term side effects or health risks.

6.  Painful for several days after the operation.
 Complications of the surgery
 Infection or bleeding at the incision
 Internal infection or bleeding
 Injury to internal organs
 Anesthetic risk: Allergic reaction or overdose

7. A woman can have sterilization anytime that:
 She decides that she will never want children in future.
 It is reasonably certain that she is not pregnant.
 Immediately after childbirth or within 7days, if she has
made a voluntary informed choice in advance
 Six weeks or more after childbirth
 Immediately after abortion (within 48 hours)
 Any other, but NOT between 7 days and 6 weeks
postpartum.

8.  Minilap services- Trained MBBS doctor
 Laparoscopic sterilization -DGO, MD (Obst. &
Gynae.), MS (Surgery) trained in laparoscopic
sterilization

9.  Clients should be married (including ever-married).
 Female clients should be above the age of 22 years
and below the age of 49 years .
 The couple should have at least one child whose
age is above one year
 Clients or their spouses/partners must not have
undergone sterilization in the past (not applicable
in cases of failure of previous sterilization).

10.  Clients must be in a sound state of mind so as to
understand the full implications of sterilization.
 Mentally ill clients must be certified by a
psychiatrist, and a statement should be given by
the legal guardian/spouse regarding the
soundness of the client’s state of mind.

11. Refer to higher centre/well equipped
Hospital if
 Cardio vascular disease.
 Mod or severe HTN.
 DM> 20 Yrs with complications.
 Complicated valvular heart disease.
 Hyperthyroidism.
 Chr lung/ liver disease
 Marked obesity/ pelvic TB.

12.  Permanent procedure for preventing future
pregnancies.
 Surgical procedure that has a possibility of
complications, including failure, requiring further
management.
 Does not affect sexual pleasure, ability, or performance.
 No affect on client’s strength or her ability to perform
normal day-to-day functions.
 No protection against RTIs, STIs, or HIV/AIDS.
 Reversal of sterilization is possible, but it involves major
surgery and that its success cannot be guaranteed.

13. Female Sterilization
• A surgical procedure
About female sterilization:
• Fallopian tubes that carry eggs to the womb are blocked or cut
and sealed (womb is left untouched).
• May hurt for a few days after.
• Usually woman not put to sleep but gets injection to prevent pain.
• Usually can go home in a few hours.
• Usually cannot be reversed.
• “Please consider carefully: might you want children in the future?”
• Ask about partner’s preferences or concerns.
• Vasectomy might be another good choice. Vasectomy is simpler
and safer to perform and slightly more effective.
• One of the most effective family planning methods for women.
• Very rarely, pregnancy does occur.
• For STI/HIV/AIDS protection, also use condoms.
• Serious complications of surgery are rare (risk of anaesthesia,
need for further surgery).
“Do you want to know more about sterilization, or talk about a different method?”
If client wants to know more about
sterilization, go to next page.
Next Move:
• Permanent—for women who
will not want more children
• Very effective
• No long-term side-effects
• No protection against STIs
or HIV/AIDS
• Very safe
• Check for concerns, rumours:
“What have you heard about problems with sterilization?”
Use Appendix 10 to talk about myths about contraception.
• Explain that all women can have sterilization if they want, even
those with no children.
• Womb is NOT removed.
You will still have menstrual periods.
S1
Female
Sterilization
To discuss another method, go to a
new method tab or to Choosing
Method tab.

14. When you can have sterilization
But may need to wait if:
Most women can have
sterilization at any time
• May be
pregnant
• Gave birth
between 1 and 6
weeks ago
• Infection or
other problem in
female organs
• Some other
serious health
conditions

15. When you can have sterilization
Most women can have sterilization
at any time
But may need to wait if:
• Procedure can be done any time except between 7 days
and 6 weeks after delivery.
• Can be done up to 7 days after delivery, if she decided in
advance.
Delay sterilization until these conditions are fully treated:
• Pelvic inflammatory disease.
• Chlamydia, gonorrhoea or purulent cervicitis.
• Infection after abortion or childbirth.
• Cancer in female organs.
May need to delay with serious health conditions:
• Such as stroke, high blood pressure, or diabetes with
complications that require management before surgery.
No conditions rule out female sterilization, but some
situations require delay, referral, or special caution.
If client is unable to have sterilization
now or in this facility, refer as needed.
Next Move:
If client is able to have sterilization,
go to next page.
• If in any doubt, use pregnancy checklist in Appendix 1 or
perform pregnancy test.
• Gave birth between 1 and 6
weeks ago
• May be pregnant
• Infection or other problem in female
organs
• Some other serious health conditions
S2
Female
Sterilization

16. Before you decide
Let’s discuss:
• Temporary methods are also
available
• Sterilization is a surgical procedure
• Has risks and benefits
• Prevents having any more children
• Permanent—decision should be
carefully considered
• You can decide against procedure
any time before surgery
Are you ready to
choose this method?
Want to know more
about the procedure?

17. Before you decide
Let’s discuss:
• Explain so client understands.
• Discuss as much as needed.
• Confirm that client understands each point.
Risks
• Any surgery, including sterilization, carries risks.
• Complications are uncommon. They include infection,
bleeding, injury to organs, need for further surgery.
• Rarely, allergic reaction to local anaesthetic or other
serious complications from anaesthesia.
Benefits
• Single procedure leads to lifelong, safe, and very effective
family planning.
• Nothing to remember; no supplies.
• May help protect against ovarian cancer.
• And will not lose rights to medical, health or other services
or benefits.
• Discuss available temporary methods.
• Probably, procedure cannot be reversed.
• May not be suitable for younger women.
Make sure client understands all points. Then ask what she has decided.
Next Move:
If client understands and wants sterilization,
explain consent form (if any) and ask her to
sign.
Go to next page.
If she decides against sterilization,
help her choose another method.
S3
• Temporary methods are also available
• Sterilization is a surgical procedure
• Has risks and benefits
• Prevents having any more children
• Permanent—decision should be
carefully considered
• You can decide against
procedure any time before surgery
Female
Sterilization

18. The procedure
1. Medication helps you keep calm
and helps prevent pain
2. You stay awake
3. Small cut is made — not painful
4. Tubes are blocked or cut
5. Opening closed with stitches
6. Rest a few hours
What questions
do you have?
Small cut either
here
or
here
Afterwards:
• You should rest for 2 or 3 days
• Avoid heavy lifting for a week
• No sex for at least 1 week

19. The procedure
1. Medication helps you keep
calm and helps prevent pain
Describe the steps in sterilization procedure. Explain:
• It is a simple, safe surgical procedure that can be done in a
hospital or health centre with the right facilities.
• Often, the whole procedure (including rest time) can take just a
few hours.
• Explain how light sedation will be given—oral or intravenous.
• Explain incision—where and how.
• Encourage her to let providers know if she feels pain during
procedure.“You can ask for more pain medicine if you want it.”
• Rest in the clinic before going home.
Does client understand surgical procedure and feel confident to continue?
Next Move:
If procedure will be done now,
go to next page to advise client on what
she must remember after surgery.
If procedure planned for another day,
arrange a convenient time for client to
return.
Offer condoms to use in the meantime.
2. You stay awake
3. Small cut is made — not painful
4. Tubes are blocked or cut
5. Opening closed with stitches
6. Rest a few hours
Afterwards:
• You should rest for 2 or 3 days
• Avoid heavy lifting for a week
• No sex for at least 1 week
• No sex until all the pain is gone.
S4
Female
Sterilization

20. Medical reasons to return
In first week, come at once if:
At any time in the future, come at once
if:
• High fever
• Pus or
bleeding
from
wound
• Pain, heat,
swelling,
redness of
wound
• Steady or
worsening
pain,
cramps,
tenderness
in belly
• Faintin
g or
very
dizzy
• Pain or
tenderness
in belly, or
fainting
• You think
you may be
pregnant

21. Medical reasons to return
In first week, come at once if:
• Over 38°C in first 4 weeks and especially first week.
• Signs of infection.
• Pregnancy after sterilization is rare. But when it does
occur, 20% to 50% of these pregnancies are ectopic.
• These are signs of ectopic pregnancy.
• She should come back immediately at any time in the
future if she thinks she might be pregnant.
“Do you feel happy with your choice of method? Is there anything I can repeat or
explain?”
Remember to offer condoms for dual protection!
Last, most important message:
Last Moves:
S5
• High fever
• Pus or bleeding from wound
• Pain, heat, swelling, redness of wound
• Steady or worsening pain, cramps,
tenderness in belly
• Fainting or very dizzy
At any time in the future, come at once if:
• You think you may be pregnant
• Pain or tenderness in belly, or fainting
Female
Sterilization

22.  Interval sterilization -within 7 days of the
menstrual period (in the follicular phase)
 Post-partum sterilization -after 24 hrs up to 7 days
of delivery
 Sterilization with MTP-performed concurrently
 Laparoscopic tubal ligation should not be done
concurrently with second-trimester abortion and in
the post-partum period

23. Surgical
 Laparoscopic ligation of fallopian tube by rings,
filshe clips or cautery

24.  Minilaparotomy-interval or
postpartum by
modified Pomeroy’s technique
 LSCS ligation
 Vaginal ligation
 Can be combined
with other surgeries

25. Transluminal
 Essure – Hysteroscopic
 Quinacrine

27.  Immediately after delivery/with in 7 days
of childbirth
 Mother receptive to counselling
 Advantages
◦ Very effective, Failure rate as low as1 in 2000
in 1year
◦ Permanent, safe, lifelong
◦ No repeat visits are needed
◦ No long term side effects

28.  Disadvantages
◦ Painful at times
◦ Uncommon complications
◦ Infection, bleeding, injury to vital organs,
anaesth complications
◦ Reversal surgery expensive and difficult

29.  Unipolar or bipolar cautery
 Hulkaclips/ Filshie clips
 Fallope rings
 Recovery- 24 to 48 hrs
 Skill, expertise, instrumentation
 Cost equipment/personnel/building etc
 Patients may be discharged the same day
 Vital organ injury may occur

30.  Minilap small incision is made in suprapubic area
 Tubes ligated by modified Pomeroy’s method
 Short procedure
 Can be done as an interval procedure where
facilities of laparoscopic surgeries not available
 Segment of fallopian tube should be sent for HPE

31.  Generally done under LA
 Minimal hospital stay
 Safe
 Disadvantage
Some develop hydro salpinx, menstrual cramps,
dysmenorrhoea, dysparunea.
Operative failure 1.17%
Skilled staff needed
Obsolete now

32. Informed Consent
 Consent should not be obtained under coercion or
when the client is under sedation.
 Client must sign the consent form for sterilization
before the surgery
 Consent of spouse not required
Clinical assessment & screening of clients
Lab investigation- Hb, BS R, urine R/m
Checklist must be signed by Medical Officer

33.  Client must NPO 6 hours prior to surgery.
 Empty bowels on day of surgery, empty bladder
before entering OT
 Remove glasses, contact lenses, dentures,
jewellery
 A responsible adult must be available to
accompany the client back home after the surgery

34.  Part Preparation with trimming of hairs
 Anaesthesia Local/ General
 Surgical procedure carried out as per standard
guidelines

35.  The client may be discharged after at least 4 hrs
of procedure, when the vital signs are stable and
the client is fully awake, has passed urine, and
can walk, drink or talk.
 The client should be evaluated by the doctor
Whenever necessary, the client should be kept
overnight at the facility.
 The client must be accompanied by a responsible
adult while going home.
 Analgesics, antibiotics, and other medicines may
prescribed as required.

36.  Client must be seen within 48 hrs by lady health
care personnel
 Second FU -7th
post-operative day for the removal
of stitches and post-operative check-up. A pelvic
examination may be done, if indicated
 Third FU- one month or after the client’s first
menstrual period, whichever is earlier
 Client must return if misses period, pain, swelling,
fever or any other complaints

37.  A certificate of sterilization should be issued after
one month of the surgery or after the first
menstrual period by the Medical Officer of the
facility

38. Intra-operative complications
 Nausea and vomiting
 Vasovagal attack
 Respiratory depression
 Cardiorespiratory arrest
 Uterine perforation
 Bleeding from the mesosalpinx
 Injury to the urinary bladder
 Injury to intra-abdominal viscera (i.e. small or large bowel) and
blood vessels
 Convulsions and toxic reactions to local anaesthesia

39. Post-operative complications
 Wound sepsis
 Haematoma in the abdominal wall
 Intestinal obstruction, paralytic ileus, and
peritonitis
 Tetanus
 Incisional hernia

40.  Permanent family planning method. A woman
must think carefully and decide she will never
want any more children, before she makes the
choice.
 It is very effective and involves a safe and
simple surgery.