Postpartum Tubal Sterilization Research Articles

The efficacy of postpartum tubal sterilization training program with minilaparotomy approach in Ob/Gyn residents

ObjectivesTo evaluate the efficacy of postpartum tubal sterilization training program with minilaparotomy approach (PTSMA). Study designFrom September 2020 to November 2021, 24 first-year Obstetrics and Gynecology (Ob/Gyn) residents were randomly allocated into 2 groups of traditional apprenticeship learning (watching video clip) versus apprenticeship learning plus PTSMA attending. The program consisted of didactics followed by self-practicing with 2 stations of postpartum tubal sterilization simulators (PTSS). All participants were allowed to perform their first tubal sterilization under supervision within a few days after training. Their surgical skills were blindly evaluated by 2 experts through the recorded videos. Five domains of direct observation of procedural skills (DOPS) score introduced by Royal Thai College of Obstetricians and Gynecologists were assessed. DOPS score, operative time, blood loss and post-op complication were analyzed and compared. ResultsMedian of total DOPS score in the PTSMA group was higher than the non-PTSMA group (93 vs. 73, p = 0.020). Concerning 2 domains of DOPS score (tubal fishing and tubal sterilization), the PTSMA group had the higher median score than the non-PTSMA group (36 vs. 24, p = 0.045 and 40 vs. 32, p = 0.020). There was no significant difference observed in the median score of 3 other domains (peritoneal cavity accessing, abdominal wall closure and complication prevention), estimated blood loss and operative time. ConclusionPostpartum tubal sterilization training program with minilaparotomy approach using instructive simulators significantly improved the total DOPS score especially tubal fishing and tubal ligation skills in Ob/Gyn residents. ImplicationsThe study evidently showed the benefit of PTSMA with an inexpensive and simple to prepare models. In unexperienced operators, practicing in model prior to surgery should be encouraged to improve their operative skills.

Trends in opportunistic salpingectomy following vaginal delivery

<h3>Objectives:</h3> The fallopian tube has been implicated as the site of origin in up to 70% of ovarian carcinomas. In November 2013, the Society of Gynecologic Oncology (SGO) advised that women of average risk for ovarian cancer undergo opportunistic salpingectomy at the time of abdominal or pelvic surgery, such as hysterectomy or tubal sterilization, to reduce the risk of ovarian cancer. Opportunistic salpingectomy has previously been incorporated into various surgical procedures including cesarean section, however a paucity of data exists regarding salpingectomy following vaginal deliveries. Our objective was to assess the uptake of opportunistic salpingectomy as a form of postpartum sterilization after vaginal delivery following the 2013 release of the SGO clinical practice statement. <h3>Methods:</h3> We performed an IRB-approved, retrospective cohort study of all postpartum tubal sterilization procedures performed during delivery admissions between January 2009 and December 2019. All patients undergoing tubal sterilization within 48 hours of vaginal delivery were included. We collected patient demographics, medical history, peripartum and perioperative data. The primary outcome was proportion of sterilization procedures completed as salpingectomies before and after January 1st, 2014. Secondary outcomes included estimated blood loss (EBL), perioperative complications and readmission within 6 weeks postpartum. We used Pearson's c2 test, Fisher's exact and Student's t-test to compare the time periods. We analyzed trends using the Cochran-Mantel-Haenszel test. <h3>Results:</h3> A total of 317 postpartum sterilization procedures were performed during the study period. 113 salpingectomies were performed during or after 2014 (<i>p</i>-value < 0.001). Patient demographics before and after January 1st, 2014 did not significantly differ. In 2014, 5.9% of sterilization procedures were completed as salpingectomies. By 2019, salpingectomies comprised 80% of postpartum sterilization procedures (Figure 1, p-value for trend < 0.001). Prior to 2014, the majority of tubal sterilizations occurred with placement of occlusive Filshie Clips (53.7%). Their use decreased to 0% by 2016 (p-value for trend < 0.001). There were no differences in EBL, postoperative complications or readmission during the time periods studied. Patients undergoing tubal sterilization prior to 2014 were more likely to be prescribed opioids at discharge compared to after (OR 0.37, 95% CI [0.20-0.70]). <h3>Conclusions:</h3> Postpartum opportunistic salpingectomy rates following vaginal deliveries increased significantly from 2014 to 2019 after the release of the SGO recommendations to consider salpingectomy as an ovarian cancer prevention strategy. This trend in postpartum salpingectomy occurred without an observed increase in complications or readmissions. Opportunistic salpingectomy should be considered a safe and feasible means of potential ovarian cancer risk reduction for patients who undergo vaginal deliveries and desire immediate postpartum sterilization.

Effect of simethicone on reducing operative difficulty associated with bowel interference during minilaparotomy for modified Pomeroy salpingectomy: A randomized controlled trial,

ObjectiveTo examine the effect of simethicone on reducing operative difficulty associated with bowel interference during minilaparotomy for postpartum modified Pomeroy partial salpingectomy. Study designWe enrolled 20–45-year-old women planning the procedure from March 2018 to February 2019. We randomized participants to chew simethicone 160 mg with water 50 mL 2–8 h before surgery or no treatment. The participants were not blinded; however, surgeons, care providers, and outcome assessors were blinded to the study allocation. We measured surgeon-rated operative difficulty using a 10-cm visual analog scale that represented the difficulty perceived to be resulting from bowel interference. Secondary outcomes included operative time and intraoperative and postoperative complications. ResultsWe enrolled 60 women in each group; baseline characteristics and procedural profiles were comparable. Women in the intervention group used simethicone a median of 157 min (interquartile range 127–192) before the procedure. Surgeons rated the procedure difficulty score as 4.8 in the simethicone group and 4.5 in the control group (p = 0.57). Operative time in the two groups were 26 and 24 min, respectively (p = 0.14). We found no difference in intraoperative adverse events including blood loss and mesosalpinx tear, postoperative morbidities, hospital stay, and patient-rated satisfaction scores. ConclusionPreprocedural simethicone has no demonstrable benefit in reducing operative difficulty caused by bowel interference during minilaparotomy for postpartum tubal sterilization. ImplicationsPreprocedural simethicone as given in this study did not result in reduced bowel interference and improved procedure difficulty. Further research examining simethicone in this setting would not be worthwhile as clinically meaningful benefit is unlikely.

Aesthetic Outcomes of Intra-Umbilical Incision vs Infra-Umbilical Incision in Postpartum Tubal Sterilization: A Randomized Controlled Trial

Background: An incision inside the umbilicus is popular used in single port surgery intra-umbilical skin incision surgeries have been proven efficient and safe. When compared to infra-umbilical skin incisions, an incision wound was invisible after the operation. Why not use intra-umbilical skin incision in postpartum tubal sterilization.&#x0D; Objective: To compare aesthetic scores of an incision wound, surgical time and complications in postpartum sterilization under infra-umbilical and intra-umbilical skin incision.&#x0D; Methods: This was a randomized controlled trial conducted in Prapokkhlo Hospital, Chanthaburi, Thailand. Patients (n = 58) with informed consents were randomly assigned to one of the two skin incision techniques for postpartum sterilization (n = 29 for each arm). Surgical times were recorded. Both the patients and an independent physician made wound aesthetic assessments one week after the operation using the Patient and Observer Scar Assessment Scores (POSAS), which compares the wound to the nearby skin. T tests and exact probability statistical tests were used for statistical analysis.&#x0D; Results: The surgeon’s POSAS scores in intra-umbilical incisions were significantly closer to normal skin than those in infra-umbilical incisions (6.8 ± 1.5 vs 12.5 ± 5.0; P &lt; .001). A similar finding was observed for patient POSAS scores (6.5 ± 1.2 vs 15.4 ± 5.0; P &lt; .001). The operation times were also shorter (9.1 ± 2.8 vs 11.8 ± 4.7 minutes; P = .009). Neither intra-abdominal injuries nor wound infections were observed.&#x0D; Conclusions: Postpartum sterilization using intra-umbilical skin incision was more efficient in regard to aesthetic concerns and operation time.

Operative time in obese and nonobese women receiving postpartum tubal sterilization

Operative time in obese and nonobese women receiving postpartum tubal sterilization

The use of a low-literacy version of the Medicaid sterilization consent form to assess sterilization-related knowledge in Spanish-speaking women: results from a randomized controlled trial

ObjectiveTo learn whether a version of the Medicaid Sterilization Consent Form (SCF) adapted for populations of low-literacy can help Spanish-speaking women better understand the process and consequences of tubal sterilization. Study designWe randomly assigned Spanish-speaking women, ages 21-45 years, to review either a “standard” or “low-literacy” version of the Medicaid SCF. We assessed sterilization-related knowledge using items from the Postpartum Tubal Sterilization Knowledge questionnaire, using as the primary outcome correct identification of least four or more knowledge items and as secondary outcome participants’ preferred version of the SCF. ResultsOverall sterilization-related knowledge was low in both groups, with 33% of women (n=100) who reviewed the standard SCF form and 42% of those who reviewed the low-literacy form (n=100) correctly identifying four or more knowledge-related items (p=.19). Regarding specific items, women in the low-literacy SCF group were more likely than those in the standard SCF group to understand the permanence of sterilization (69% versus 49%, p<.01) and the time requirement between signing the consent document and undergoing sterilization (79% versus 59%, p<.01). The groups were similar in appreciating availability of equally effective nonpermanent contraceptive options (71% versus 64%, p=.29), time from signing to expiration (33% versus 38%, p=.46), or non-binding nature of sterilization consent (55% versus 62%, p=.32). Overall, 71% of participants from both groups preferred the low-literacy form. ConclusionIn our patient population, characterized by low educational attainment and inadequate health literacy skills, a low-literacy SCF did not improve overall sterilization-related knowledge when compared to the standard SCF. The low-literacy version did improve understanding of the permanence of sterilization and time requirements to undergo the procedure. ImplicationsNeither form conveyed an adequate level of knowledge to this vulnerable Spanish-speaking population. Therefore, a considerable need persists for detailed education regarding availability of equally effective reversible contraceptive options, procedure-related risks, and permanence of sterilization throughout the process of informed consent.

Bilateral Tubal Ligation after Parturition Among Medicaid Patients in West Virginia: An Institutional Experience

Postpartum tubal ligation is one of the safest and most effective methods of contraception. Yet, not all women who desire it actually undergo the procedure. We studied clinical and demographic factors that were associated with receipt of tuba ligation among West Virginia Medicaid patients. A retrospective study was performed evaluating Medicaid patients in West Virginia requesting postpartum sterilization from May 2012 to November 2014 (N = 153). Demographic information was obtained on these patients. Clinical factors complicating pregnancy were analyzed. For those patients choosing not to undergo tubal sterilization, contraceptive plan at discharge was also evaluated. Statistical tests included Chi square and Fisher’s Exact Test where appropriate. 71% (n=96) received tubal ligation before discharge. 21% (n = 29) requesting post-partum tubal ligation went unsterilized. Women with a history of cesarean section (83% vs. 61%; p = <0.0007) and those delivering by cesarean section rather than vaginal delivery (86% vs. 55%; p = <0.001) were more likely to receive tubal ligation. All other factors did not significantly influence the completion rate for tubal sterilization. Twenty one percent of patients requesting post-partum tubal sterilization went unfulfilled, indicating that significant barriers remain.

Trends and Disparities in Postpartum Sterilization after Cesarean Section, 2000 through 2008

PurposeTubal sterilization patterns are influenced by factors including patient race, ethnicity, level of education, method of payment, and hospital size and affiliation. However, less is known about how these factors influence tubal sterilizations performed as secondary procedures after cesarean sections (C-sections). Thus, this study examines variations in the prevalence of postpartum tubal sterilizations after C-sections from 2000 to 2008. MethodsWe used data from the National Hospital Discharge Survey to estimate odds ratios for patient-level (race, marital status, age) and system-level (hospital size, type, region) factors on the likelihood of receiving tubal sterilization after C-section. ResultsA disproportionate share of postpartum tubal sterilizations after C-section was covered by Medicaid. The likelihood of undergoing sterilization was increased for Black women, women of older age, and non-single women. Additionally, they were increased in proprietary and government hospitals, smaller hospital settings, and the Southern United States. ConclusionsOur findings indicate that Black women and those with Medicaid coverage in particular were substantially more likely to undergo postpartum tubal sterilization after C-section. We also found that hospital characteristics and region were significant predictors. This adds to the growing body of evidence that suggests that tubal sterilization may be a disparity issue patterned by multiple factors and calls for greater understanding of the role of patient-, provider-, and system-level characteristics on such outcomes.

Health care justice and its implications for current policy of a mandatory waiting period for elective tubal sterilization

Tubal sterilization during the immediate postpartum period is 1 of the most common forms of contraception in the United States. This time of the procedure has the advantage of 1-time hospitalization, which results in ease and convenience for the woman. The USCollaborative Review of Sterilization Study indicates the high efficacy and effectiveness of postpartum tubal sterilization. Oral and written informed consent is the ethical and legal standard for the performance of elective tubal sterilization for permanent contraception for all patients, regardless of source of payment. Current health care policy and practice regarding elective tubal sterilization for Medicaid beneficiaries places a unique requirement on these patients and their obstetricians: a mandatory waiting period. This requirement originates in decades-old legislation, which we briefly describe. We then introduce the concept of health care justice in professional obstetric ethics and explain how it originates in the ethical concepts of medicine as a profession and of being a patient and its deontologic and consequentialist dimensions. We next identify the implications of health care justice for the current policy of a mandatory 30-day waiting period. We conclude that Medicaid policy allocates access to elective tubal sterilization differently, based on source of payment and gender, which violates health care justice in both its deontologic and consequentialist dimensions. Obstetricians should invoke health care justice in women's health care as the basis for advocacy for needed change in law and health policy, to eliminate health care injustice in women's access to elective tubal sterilization.

232-POS

Objectives Hypertensive disorders represent the major cause of maternal morbidity in middle income countries. Chronic hypertension occurs in up to 5% of pregnant women with special challenges to health care providers. Complications depend on the hypertension etiology, duration and severity. Chronic hypertension is a known risk factor for superimposed preeclampsia, with worse maternal-fetal outcomes. Objective: to describe maternal and perinatal outcomes of pregnancies complicated by chronic hypertension followed at the State University of Campina’s high risk outpatient clinic during an 18 months period. Methods Retrospective study with chart review of pregnancies complicated by chronic hypertension at the State University of Campinas (from January/2012 to June/2013). Results 113 women were considered, with mean age of 33 years, mostly white (56%), with partner (82%), multiparous (76%), education over elementary (62%). Mean duration of hypertension was 7 years and most women used anti-hypertensive drugs prior to pregnancy (65%) and were obese (53%). The majority used low dose aspirin and calcium during prenatal care (95%). Over 90% used anti-hypertensive drugs during pregnancy. Mean number of prenatal care visits was 9, with mean referral to high-risk clinic around 16 weeks. The majority of women were evaluated by a cardiologist (83%) with only 3.5% cardiac disease diagnosed. Superimposed preeclampsia occurred in 21% of all cases, with 13% of Intensive Care Unit admissions. Fetal assessment by Doppler velocimetry was systematically performed after 28 weeks of gestation, and only 9 pregnancies (8%) presented fetal distress. Mean gestational age at resolution was 37 weeks and mean fetal weight at birth 2960 g. C-section was performed in 68% of all cases and 58 women underwent postpartum tubal sterilization. Conclusions Pregnancies complicated by chronic hypertension should be referred to high-risk prenatal care assistance. There is increased risk of superimposed preeclampsia and clinical and fetal surveillance are essential to guarantee adequate outcomes. Disclosures M.T. Moreno: None. A.C. Cortez: None. F. Cavichiolli: None. M.A. Parpinelli: None. F.G. Surita: None. M. Costa: None.

Unmet postpartum sterilization demand at an urban tertiary care center: associated factors and alternate contraception

Unmet demand for postpartum tubal sterilization (PPBTL) is prevalent. We investigate unfulfilled PPBTL and alternate birth control methods (BCM) in an obstetric population with variable medical complexity.

Hospital Variation in Postpartum Tubal Sterilization Rates in California and Texas

To estimate variation across hospitals in the rate of postpartum sterilization. All hospitals with deliveries in California and Texas in 2009 were included. Proportion of live singleton deliveries with postpartum sterilization was calculated by hospital, insurance status (Medicaid compared with private insurance), type of delivery, and state. Within each insurance status in California and Texas, we found wide variations across hospitals in postpartum tubal sterilization rates. This variability was not explained by disparities in hospital cesarean delivery rates. Some, but not all, of this variation was attributable to the absence of sterilizations in Catholic hospitals. Overall, postpartum tubal sterilization rates were higher in Texas than in California (10.2% compared with 6.7%), and this difference was found among both public insurance and private insurance patients. Interval sterilizations were more frequent in California, but the difference was not large enough to offset the difference in postpartum sterilization. The variation in postpartum tubal sterilization rates across hospitals is substantial and exists even among hospitals without religious affiliations. Large-scale studies are needed to assess the demand for, and the barriers to, obtaining postpartum sterilization. II.

Hospital variation in postpartum tubal sterilization rates in California and Texas

About half of all female sterilizations are performed immediately postpartum. However, there may be significant barriers to getting a postpartum tubal sterilization for Medicaid and private patients. We examine variation across hospitals in the proportion of deliveries followed by postpartum tubal ligation (PPTL) in two large states, California and Texas.

Committee Opinion No. 530

Postpartum tubal sterilization is one of the safest and most effective methods of contraception. Women who desire this type of sterilization typically undergo thorough counseling and informed consent during prenatal care and reiterate their desire for postpartum sterilization at the time of their hospital admission. Not all women who desire postpartum sterilization actually undergo the surgical procedure, and women with unfulfilled requests for postpartum sterilization have a high rate of repeat pregnancy (approaching 50%) within the following year. Potentially correctable barriers to obtaining postpartum sterilization include patient and health care provider factors, as well as hospital and health care system issues. Given the consequences of a missed procedure and the limited time frame in which it may be performed, postpartum sterilization should be considered an urgent surgical procedure. In addition, women with government insurance face barriers to sterilization procedures based on cumbersome consent requirements. The differences in the requirements surrounding consent for sterilization procedures based on the type of insurance a patient has must be addressed in order to establish fair and equitable access to sterilization procedures for all women. Policies and procedures that remove barriers to and increase efficiency in performing postpartum sterilization could reduce cancellations of the procedure. Improving consistency in accomplishing desired postpartum sterilization is an important strategy to reduce high rates of unintended pregnancy in the United States.

Postpartum intrauterine device insertion and postpartum tubal sterilization in the United States

Postpartum intrauterine device insertion and postpartum tubal sterilization in the United States

Postpartum intrauterine device insertion and postpartum tubal sterilization in the United States

The purpose of this study was to estimate US rates of postpartum intrauterine device (IUD) insertion and postpartum tubal sterilization. Data from the 2001-2008 Nationwide Inpatient Sample were used to identify delivery hospitalizations with IUD insertion or tubal sterilization procedure codes. Estimated rates of postpartum IUD insertion and postpartum tubal sterilization were 0.27 and 770.67 per 10,000 deliveries, respectively. Although the rate of IUD insertion was similar across age groups, the rate of tubal sterilization increased with age. Nonetheless, 15% of tubal sterilizations occurred among women who were ≤ 24 years old. IUD insertion was more likely among women who delivered at teaching hospitals (odds ratio, 3.02; 95% confidence interval, 1.43-6.37); tubal sterilization was more likely among women without private insurance (odds ratio, 2.04; 95% confidence interval, 1.97-2.11). Among US postpartum women, IUD insertion occurs considerably less frequently than tubal sterilization, even among younger women for whom poststerilization regret is a concern.

Use of a Low-Literacy Informed Consent Form to Improve Women's Understanding of Tubal Sterilization

To estimate whether the Medicaid-Title XIX Sterilization Consent Form (SCF) format--"standard" compared with "low-literacy"--is associated with women's understanding of tubal sterilization. This study was a randomized trial that took place in an obstetrics and gynecology residency clinic in the southeastern United States. Women, aged 21 to 45 years, were randomly allocated to receive a copy of either the standard or the low-literacy Medicaid-Title XIX SCF. A research assistant assessed women's sociodemographic characteristics, health-literacy skills, and understanding of sterilization using items from the Postpartum Tubal Sterilization Knowledge questionnaire. Women were also queried regarding their preferences for either version of the Medicaid-Title XIX SCF. We included 201 women in the study. Compared with women in the standard group (n=99), women in the low-literacy group (n=102) with no additional counseling better understood the length of time required between signing the form and undergoing sterilization (23.6% difference between groups, P<.01), the time interval until the form expired (33.7% difference between groups, P<.01), permanence of sterilization (15.7% difference between groups, P=.01), and that nonpermanent contraceptive options as effective as sterilization are available (8.2% difference between groups, P=.02). When given the choice to select either Medicaid-Title XIX SCF, 189 (94%) preferred the low-literacy version. Our results support replacing the standard Medicaid-Title XIX SCF with the low-literacy version to foster increased understanding of sterilization.

Development and validation of a Medicaid Postpartum Tubal Sterilization Knowledge Questionnaire

We sought to describe the development and validation of the Postpartum Tubal Sterilization Knowledge Questionnaire (PTSK-Q), a survey designed to assess Medicaid recipients' understanding of the postpartum tubal sterilization process. Initially, the investigators generated a list of 17 potential items to include in the PTSK-Q. Eleven content experts reviewed two drafts of the PTSK-Q and provided qualitative and quantitative assessments. Eight women completed a field test to determine suitability and clarity of individual PTSK-Q items, while 26 women completed a pilot test to determine internal consistency and test-retest reliability of the PTSK-Q. The Flesch Reading Ease (FRE) was used to assess reading grade level of the PTSK-Q. Seven items were rated as "essential" (content validity ratio=p<.05) by content experts and composed the final PTSK-Q. Internal consistency, using Kuder Richardson-20, was 0.68. Test-retest reliability, using intraclass correlation coefficient, was 0.93. The FRE score of the PTSK-Q was 85.14 (sixth reading grade level). The PTSK-Q is a valid, readable and reliable knowledge assessment instrument for assessing understanding of postpartum sterilization and Medicaid sterilization consent requirements.

Randomized trial to evaluate the use of a flexible self-retaining retractor for postpartum tubal sterilization: a pilot study

Postpartum tubal ligation is a safe and effective means of contraception, but it is being performed less frequently than in the past. One reason for the decrease includes inconvenient scheduling for the physician. If a device that makes surgery easier to perform were available, perhaps more physicians would offer this option. In this study, we sought to compare a flexible self-retaining retractor (Mobius��; Apple Medical Corporation) with standard metal retractors (Army���Navy) for use in postpartum bilateral tubal ligation.

Barriers to obtaining a desired postpartum tubal sterilization

Objective To determine why women do not undergo postpartum sterilization despite expressing desire during antepartum care. Methods In a retrospective chart review, we identified all women between March 2002 and November 2003 who requested postpartum sterilization during antepartum care but did not undergo the procedure. We report the reasons why sterilizations were not performed. Results We reviewed 6589 prenatal care and delivery records identifying 324 women meeting inclusion criteria. One hundred and four women changed their mind. Of women still desiring sterilization at discharge, the most common reasons for not undergoing the procedure were lack of valid Medicaid sterilization consent forms [ n=121; 37.3%, 95% confidence interval (CI) 32.0–42.6%]; a medical condition precluding the procedure ( n=47; 14.5%, 95% CI 10.7–18.3%); lack of availability of an operating room ( n=2; 6.5%, 95% CI 3.8–9.2%). Conclusion We found that the Medicaid consent process, medical conditions and insufficient operating room space prevented women from having the desired surgery.