BRENDA A. BUCKLIN AND CARL V. SMITH
Departments of Anesthesiology and Obstetrics and Gynecology, University of Nebraska Medical Center, Omaha, Nebraska
Anesth. Analg., 89: 1269–1274, 1999
Tubal sterilization is the form of birth control most often used by women in the United States. The procedure is frequently performed after vaginal or cesarean delivery, but several factors should be considered before postpartum tubal ligation is done. Anesthetic concerns may influence the timing of the procedure. The authors review the timing and controversial aspects of postpartum tubal ligation.
The timing of tubal sterilization has changed with the reductions in length of hospital stay after childbirth. Postpartum sterilization within 8 hr of delivery is reasonable if the delivery had no complications and the mother’s medical history is uncomplicated. However, performing sterilization this quickly after delivery does not allow enough time to properly assess the newborn. Should problems arise, tubal ligation may be delayed for the consideration of a subsequent pregnancy. The decision to proceed with sterilization in a high-risk patient must be considered when a subsequent pregnancy could contribute to maternal morbidity/mortality. Staff availability is another consideration because the procedure should not be performed when it might compromise other aspects of patient care.
The true anesthetic risk for postpartum sterilization within 8 hr of delivery is unknown, but many sterilizations are performed within this time period, and reports of complications are rare. The choice of anesthetic technique should be individualized, based on anesthetic or obstetric risk factors and patient preference. The decision to use general anesthesia within 8 hr of delivery should be considered carefully. Airway changes can persist for some time after delivery, and these changes may contribute to laryngeal edema and airway difficulty during postpartum tubal sterilization.
Delays in gastric emptying may persist during the early postpartum period and various factors should be considered. Solid food intake and intrapartum opioid administration may contribute to delays in gastric emptying. In such instances sterilization may be delayed to improve gastric emptying.
Choice of neuraxial anesthesia will depend on patient preference, existence of a functional epidural catheter, and the interval from delivery to sterilization. Other factors include epidural catheter movement resulting in inadequate analgesia, depth of original epidural catheter insertion, and need for supplemental anesthesia. Short-acting anesthetics are preferred for spinal anesthesia for ligation procedures. The effectiveness of using local anesthetic for ligation has been questioned. Although the comparative benefits of each anesthetic technique have not been assessed, the timing of the procedure and the decision to use a particular anesthetic technique should be individualized, based on anesthetic and obstetric risk factors and the woman’s preference.
This is an excellent review article that covers all issues regarding postpartum tubal ligation after vaginal delivery. The need for the tubal ligation to be performed within 8–12 hr of delivery has become a necessity owing to shorter hospital stays. This affects both anesthesiology staffing and nursing staffing, because in most institutions it is impractical to use nonlabor and delivery operating rooms for such a procedure since it can neither be scheduled nor considered an emergency procedure.
The issues of gastric emptying and aspiration risk as well as airway management are of concern in the debate over immediate postpartum tubal ligation. As the authors have underscored, there is delayed gastric emptying in patients related to their postpartum status as well as to opioid administration either parenterally or epidurally during the course of labor. The authors suggest that a history of recent solid food intake or intrapartum opioids combined with the patient’s refusal for regional anesthesia should result in a delay in scheduling of the tubal ligation. The issue of epidural reactivation is controversial, with the best studies suggesting that only 93% of labor epidurals can successfully be reactivated. In our institution spinal anesthesia is the anesthetic of choice.
The authors should be commended in providing a very thorough review of the topic, allowing practitioners to know the controversies that exist with respect to timing and safety of postpartum tubal ligation. This review should act as a basis for any department’s decision-making regarding the management of these patients.
Ferne B. Sevarino M.D.