CLINICAL GUIDELINES ID TAG Female Sterilisation (tubal occlusion) at Caesarean Section- Guideline for counselling and consent

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1 Title: Author: Designation: Speciality / Division: Directorate: CLINICAL GUIDELINES ID TAG Female Sterilisation (tubal occlusion) at Caesarean Section- Guideline for counselling and consent Dr Meeta Kamath Consultant Obstetrics-IMWH Acute Services Date: July 2018 Consulted upon: Authorised by Yes Mr David Sim Ms Patricia McStay Approved by: (Name of AMD) Applicable to: (delete Yes / No as appropriate) Review Date (Every 2 years or sooner if required): CG ID TAG Dr Martina Hogan Dept./Division Only: YES-IMWH Directorate Only: NO Trust-wide: NO August 2021 CG0129[1]

2 Guideline for female Sterilisation (tubal occlusion) at Caesarean Section First occasion Summary If a woman requests sterilisation at Caesarean section she must talk to a doctor who must discuss and document in the chart the following points the first time she requests the procedure. Ideally this is at booking: 1. Permanent procedure 2. Risk of pregnancy is 1 in 100 to 200 with sterilization at C/section 3. Alternatives may be better as some are reversible or equally or more effective e.g. mirena or implant 4. Risk of pregnancy is 1 in 2000 with male sterilisation/vasectomy 5. Risk of ectopic pregnancy 6. There is a risk of regret 7. The health of the baby is not always certain at the time that the operation is carried out 8. Not always technically possible or safe 9. Information leaflets should be given When arranging/booking the Caesarean section When the planned Caesarean section is being booked the desire to have tubal occlusion should be confirmed with the woman and documented in her chart. When consenting for Caesarean section When consent for caesarean section is being obtained, consent for tubal occlusion should be obtained. The above points should be included on the written consent form. The written consent should ideally be performed at least 24 hours before the operation and the patient s copy of the consent form given to the women to read in advance of the operation day. On the day of Caesarean section The woman s intentions to have a tubal occlusion should be confirmed with her Further information Tubal Occlusion is a major decision. It means that women (and her partner) do not want children at any time in the future. A woman s decision to undergo tubal occlusion must be voluntary and not forced by

3 her family, partner or healthcare provider. Ideally both partners should have an understanding of the procedure as well as the tubal occlusion s benefits, alternatives and potential risks. Tubal ligation at Caesarean section can only be planned in women in whom an elective Caesarean section is planned and should not be a last minute or emergency decision. The discussion of tubal ligation should be done in a formal setting, ideally in the booking visit initially and further discussion in subsequent antenatal visits. There should be a detailed discussion including the details of the procedure, the pros and cons, the risks and benefits of all methods of contraception, including male sterilisation, the risks of surgery and the risks of anaesthesia. The patient should be given adequate time to process this information and should have leaflets to take home (e.g. family planning leaflet outlining all contraceptive methods). A woman may decline tubal occlusion at any time up until it has been performed. Points that should be discussed with the patient and documented in the chart: 1 - Tubal occlusion should be considered permanent; reversing the procedure involves major surgery which is associated with limited success. Reports suggest that between 3 and 25% of women regret their decision to undergo sterilisation. However, only 1-2% undergoes a reversal of the procedure. Regret has been reported more commonly when the procedure is performed in correlation with pregnancy. The most common factor associated with regret is a change in marital status. Other factors include marital problems at the time of the procedure, stress due to recent pregnancy complications, and young age at the time of sterilisation. Given this, women who are younger than 30, have recently given birth and had significant complications or who are having difficulty with their marriage or relationship should consider reversible contraception. 2 - The patient should be advised about other long-term reversible methods of contraception such as the contraceptive pill, coils, implants, injections, patches and barrier methods. It should be explained that male sterilisation, a vasectomy is a simpler and easier procedure with a failure

4 rate of 1 in The mirena coil and contraceptive implant provide similar contraception to sterilisation but are reversible. 3- Procedure- After delivery of the baby and closure of the uterus, the fallopian tubes are divided and tied. Specimens of fallopian tube are sent for histopathological confirmation. Other option [DHH] is to place a titanium clip [Filshie clip] across each fallopian tube to completely obstruct it. Also in CAH, salpingectomies considered as an option and specimens of fallopian tube are sent for histopathological confirmation 4 - Complications of tubal occlusion occur in approximately 1 in 1000 procedures. The most common complications include infection, bowel or bladder injury, bleeding and problems related to anaesthesia. 5 Women should be made aware of the possibility of failure, 1 in 200, even in a competently performed tubal occlusion. In one study women were observed for 8 to 14 years, approximately 1% of women become pregnant. The risk was highest among women who were less than 30 years of age. 6 - When pregnancy occurs after tubal occlusion it is more likely to be an ectopic pregnancy. Therefore if a woman is to miss a period following the procedure she should seek medical advice. 7 - Ideally consent for sterilisation should be given prior to admission for the proposed caesarean section. Decisions at the time of surgery should not be accepted. 8 - In difficult cases the consultant or senior obstetrician should be involved in the discussion. 9 - There is no evidence that menstrual irregularities occur after sterilisation It does not affect sexual desire or performance. References Grubb GS, Peterson HB, Layde PM, Rubin GL. Regret after decision to have a tubal sterilization. Fertil Steril 1985; 44:248.

5 Allyn DP, Leton DA, Westcott NA, Hale RW. Presterilization counselling and women's regret about having been sterilized. J Reprod Med 1986; 31:1027. Wilcox LS, Chu SY, Eaker ED, et al. Risk factors for regret after tubal sterilization: 5 years of follow-up in a prospective study. Fertil Steril 1991; 55:927. Peterson HB, Xia Z, Hughes JM, et al. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996; 174:1161. Female sterilization RCOG Consent Advice No. 3-February 2016