Female sterilisation

1. Female Sterilisation Department of Obstetrics and Gynaecology

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3. Normal Anatomy:

4. Anatomy: Length- 10-14cm Diameter- 2-6mm Lat-Med- Infundibulum with fimbriae , Ampullary , Isthmus, interstitial. Blood Supply-Br. of uterine and ovarian artery Nerve Supply-Sympathetic and Parasym . T11-12 & L1 Lymphatic drainage- iliac & lateral aortic nodes

5. Fallopian tube : Interstitial-narrowest 1mm Ampulla longest and widest Fertilization Junction of ampulla & isthmus Histology 3layers Serosa primarily visceral peritoneum Sub- serosa Muscularis Mucosa 3different cell types

6. Physiological function: Ovum pick-up Capacitation of spermatozoa Acrosomal reaction Facilitation of fertilization Transfer of zygote to uterus for implantation

7. Human Ovum :

8. Human Spermatozoa :

9. Fertilizatin :

10. Case Selection ( Self-declaration by the client will be the basis for compiling this information.) Patients should be married. Female Patients age ˂ 49 years and ˃ 22 years. The couple should have at least one child whose age is above one year. Patients or their spouses/partners must not have undergone sterilization in the past. Patients must be in a sound state of mind. Mentally ill clients must be certified.

11. Counselling : Patients must be informed of all the available methods of family planning made aware that this operation is a permanent one. Clients must make an informed decision for sterilization voluntarily. Patients counseled in their language. Patients should be informed about the surgery and its complications.

12. Features of Female Sterilization: Permanent procedure. Surgical complications &failures &further management. No effect on couple life. No effect daily activity. No protection to STD or HIV. Reversal possible but a major surgery and less success rate.

13. Women Experiencing an Unintended Pregnancy Within the First year of Use (%) Method Typical Use Perfect Use Women Continuing Use at 1 Year (%) No method 85 85 Spermicides 29 18 42 Withdrawal 27 4 43 Periodic abstinence 25 51 Calendar 9 Diaphragm 16 6 57 Female (Reality) 21 5 49 Male 15 2 53 Combined pill and minipill 8 0.3 68 Female sterilization 0.5 0.5 100 Male sterilization 0.15 0.10 100

14. Clinical Selection of a Case: Demographic information Medical History Physical examination Laboratory examination

15. Timing of Sterilization: Interval sterilization should be performed in the follicular phase of the menstrual cycle). Post-partum sterilization should be done after 24 hours up to 7 days of delivery. Sterilization with medical termination of pregnancy (MTP) can be performed concurrently. Sterilization following spontaneous abortion provided the client fulfils the medical eligibility criteria.

16. Pre-operative Care: Pre-medication Analgesia or Anaesthesia - Local Anaesthesia Anaesthesia of Choice. General Anestheisa rare but In case of a non-cooperative patient In case of excessive obesity In case of a history of allergy to local anaesthetic drugs Monitoring Pre-operatively Intra-operatively Post-operatively

17. Surgery: General Requirements Bladder empty Surgeon to identify both fallopian tube up to fimbria Occlusion should be 2-3cm from cornu & in isthmus Excision of 1cm of tube No crushing or use of cautery Incision closure by either absorbable or non- absorbale suture.

18. Surgical Techniques:

19. Pomeroy: Loop is made consisting major part of isthmus & ampulla Avascular mesosalphix needle 0 chr . Catgut is passed and tied firmly About 1-1.5cm of segment of loop distal to ligature is excised . About 1.5cm intact tube adjacent to uterus left. Specimen sent for histology.

20. Uchida Isthmus portion grasped and subserosa infiltrated and incised Muscular portion identified and divided Serosa dissected bluntly and exposed muscular portion ligated and resected Proximal portion buried in mesosalhinx and distal one kept open to peritoneal

21. Irving

22. Parkland

23. Points Modified pomeroy is most common method Uchida has least chance of failure among all Irving & Parkland method are rare in use Suture used is 1chromic catgut Absorbable suture used to prevent recananlization

24. Laparocopic Sterilization : Requirements Trendelenberg position ˃15˚ Uterine elevator used Pneumoperitoneum Insufflation with CO 2 Falope ring used. Other methods spring clip Hulka & Titanium clip After application abdomen should carefully inspected Expel gas before removing the port

25. Post-operative Care Post-operative BP, pulse & respiration/15min Patient can be discharged Stable for 4hours Passed urine, walk, drink & talk. Evaluated by doctor Patient accompanied by responsible adult Antibiotics, analgesics, etc provided or prescribed.

26. Electrocoagulation : Unipolar was first to be used Least chance of failure Causes most thermal injury to adjacent organs Bipolar is more safe but with higher ligation failure Central Govt. policy is no use of cautery

27. Complications : Nausea and vomiting Vasovagal attack Respiratory depression Cardiorespiratory arrest Uterine perforation Bleeding from mesosalpinx Injury to urinary bladder Injury to bowel or vessel Convulsion and toxic reaction to anaesthetic drugs

28. Post-operative Care: Wound sepsis Haematoma in the abdominal wall Intestinal obstruction, paralytic ileus and peritonitis Tetanus Incisional hernia

29. Conditions Unrelated to Ligations : Menstrual irregularities Scanty periods Menorrhagia Chronic pelvic inflammatory disease Psychological problems Sexual function

30. Hysteroscopic Ligation Essure : The Essure system is a type of permanent birth control for women. The Essure system includes two small metal and fiber coils that are placed in the fallopian tubes. They're inserted through the vagina, so no incision is required. 3months other contraceptive use is necessary HSG to be done to ensure the tubal block Does not prevent STI

31. Benefits Permanence Effectiveness Lack of significant long-term side effects No need to buy contraception, interrupt sex for contraception or seek partner compliance No incision Convenience — the Essure system can be implanted at your health care provider's office No effect on your menstrual cycle

32. Discourage if Are sensitive to nickel or allergic to the contrast agent used to confirm tubal blockage Have a uterine or tubal condition that prevents access to one or both tubal openings Might want to become pregnant Previously had a tubal ligation Recently gave birth or had an abortion Recently had a pelvic infection

33. Risks Infection Pelvic pain Perforation of the uterus or fallopian tubes Tubal blockage occurring on only one side No ablative surgery of uterus If client conceieves with essure then more chances of ectopic pregnancy.