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In order, therefore, to render a woman permanently sterile by an operation upon the tubes, they must be excised by wedge-shaped incisions at the cornua of the uterus and the wounds closed by sutures.

—J. Whitridge Williams (1903)

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INTRODUCTION

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Sterilization is a popular choice of contraception for millions of men and women. Among women using contraception, one third rely on either male or female sterilization (Daniels, 2015). This procedure is indicated in those requesting sterilization and who clearly understand its permanence and its difficult and often unsuccessful reversal. All persons considering sterilization should also be counseled regarding alternative contraceptive choices (American College of Obstetricians and Gynecologists, 2009, 2015a).

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Female sterilization is usually accomplished by occlusion, excision, or division of the fallopian tubes. Puerperal sterilization procedures follow cesarean or vaginal delivery and approximately 8 percent of all live births in the United States (Chan, 2010). Nonpuerperal tubal sterilization is done at a time unrelated to recent pregnancy and is also termed interval sterilization.

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PUERPERAL TUBAL STERILIZATION

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Timing

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For several days postpartum, the uterine fundus lies at the level of the umbilicus, and fallopian tubes are accessible directly beneath the abdominal wall. Moreover, abdominal laxity allows easy repositioning of the incision over each uterine cornu.

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On our service, puerperal tubal ligation is performed by a surgical team dedicated to this role the morning after delivery. This timing minimizes hospital stay but lowers the likelihood that postpartum hemorrhage would complicate recovery following surgery. In addition, the status of the newborn can be better ascertained before surgery. In contrast, some prefer to perform sterilization immediately following delivery and use neuraxial analgesia already placed for labor. In this model, barriers to sterilization can be lessened by designating these postpartum surgeries as urgent, especially in high-volume labor and delivery units, which usually prioritize limited operating-room availability for intrapartum procedures (American College of Obstetricians and Gynecologists, 2014; Potter, 2013).

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Technique

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Various techniques are now used to disrupt tubal patency. In general, a midtubal segment of fallopian tube is excised, and the severed ends seal by fibrosis and peritoneal regrowth. Commonly used methods of puerperal sterilization include the Parkland, Pomeroy, and modified Pomeroy techniques (American College of Obstetricians and Gynecologists, 2015a). Less often, Filshie clips are used (Madari, 2011). Irving and Uchida techniques or Kroener fimbriectomy are rarely used because of their increased required dissection or unfavorably high failure rates. Also, in the absence of uterine or other pelvic disease, hysterectomy solely for sterilization at the time of cesarean delivery, early in the puerperium, or even remote from pregnancy is difficult to justify. It carries significantly increased surgical morbidity compared with tubal sterilization.

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Evidence suggests that the fallopian tube may be the origin of pelvic serous carcinomas, especially those of the ovary. With this ...

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