Guidelines 2016 – Sterilization
Guidelines for Nurse Practitioners in Gynecologic Settings 2016
I. DEFINITION
sterilization in women is the purposeful occlusion of the fallopian tubes by surgical disruption or an occlusion device. several methods are prac- ticed through closed laparoscopy, open laparoscopy, or suprapubic mini- laparotomy. the method of tubal occlusion depends on the surgical route. these occlusion methods include excision of a portion of each tube and suturing of the ends; excision of the fimbriated end; excision of a portion and then suturing of the proximal end into the muscle of the uterus and of the distal end in the broad ligament; banding with silastic bands (falope rings, yoon band) or clips (hulka-Clemens clip, filshie clip); ligation of a loop of the tubes with nonabsorbable suture material; and occlusion by bipolar cautery. another method is transcervical to place the essure tubal occlusion device.
II. BACKGROUND FOR ELECTING STERILIZATION
decision by the woman to seek permanent sterilization through tubal ligation or occlusion as a means of fertility regulation
III. HISTORY
a. What the woman may present with
1. history of use of one or more methods of contraception
2. dissatisfaction with available methods and/or method failure
3. experiencing problems with one or more methods and a decision not to have any more children
4. Medical contraindications for use of one or more methods
5. psychosocial contraindications for use of one or more methods
6. desire to have no more children or no children at all; need or desire for permanent method
7. premenopause, less than 1 year without a period
B. additional information to be obtained
1. Knowledge about all family planning methods used
2. psychosocial and cultural aspects: size of family desired, beliefs about sterilization, family attitudes
3. Knowledge about the sterilization procedures available and beliefs about reversibility
4. history of any previous pelvic surgery, partial or total hysterectomy, oophorectomy, salpingectomy, laparoscopy, assisted reproductive procedures, or plastic surgery such as tubal reconstruction
5. Medical/surgical history, present use of medications
6. type of anesthesia for previous surgeries, any untoward effects
7. gynecologic and obstetric history: pregnancies, live births, abor- tions, ectopic pregnancies, endometriosis, uterine anomalies, pres- ence of adhesions, uterine leiomyomas (fibroids)
8. Menstrual history to the present, last period, premenstrual syn- drome (pMs), character of menses and menstrual cycle
9. Contraceptive use to present and reasons for discontinuation
IV. PHYSICAL EXAMINATION
a. Vital signs
1. Bp
2. pulse
B. general physical exam: lungs, heart, neck, abdomen, breasts, extremi- ties, thyroid
C. pelvic examination
1. external: skene’s glands, Bartholin’s glands, urethra, labia, fourchette
2. Vaginal examination: walls, discharge, cervix; inspect for cysto- cele, rectocele, urethrocele
3. Uterus: masses, tenderness, enlargement, possible pregnancy
4. adnexa: masses, tenderness, palpable ovaries or tubes, enlargement
V. LABORATORY EXAMINATION (FOR PREOPERATIVE WORKUP ONLY OR FOR SYMPTOMS OF PROBLEM)
a. Urinalysis, culture if signs of urinary tract infection
B. Complete blood count (CBC)
C. pregnancy test
d. gonorrhea culture
e. Chlamydia test
f. pap smear
VI. DIFFERENTIAL DIAGNOSIS
none
VII. TREATMENT
a. teaching
1. Methods of sterilization and possible failure
2. Chance of future reversal; choice of method of sterilization related to this
3. information on informed consent
4. risks and benefits
5. discussion of regret
6. information on waiting period
7. postoperative implications (i.e., restrictions)
8. sexual adjustments following procedure
9. information on possible posttubal ligation syndrome
VIII. COMPLICATIONS
Conditions contraindicating procedure or choice of procedure, such as previous surgery or extensive adhesions; allergy or untoward response to anesthesia
IX. CONSULTATION/REFERRAL
to clinician who performs tubal ligations if the procedure is not offered in the practice setting
X. FOLLOW-UP
a. definition
1. follow-up care after the completion of sterilization by tubal liga- tion or occlusion
2. time of follow-up will vary depending on the procedure performed
B. history
1. type of procedure done, date of the procedure, anesthesia used
2. any sutures to be removed
3. Menstruation: last menstrual period, character
4. resumption of sexual activity, response; change in sexual habits
5. What patient may present with
a. pain, fever, bleeding, or discharge from operative site
b. abdominal pain, pelvic pain, shoulder pain
c. Vaginal discharge
d. Urinary symptoms: frequency, dysuria, hematuria
e. any new symptoms/concerns with menstrual cycle not experi- enced prior to tubal ligation, such as endocrine manifestations
C. physical examination
1. Vital signs
a. pulse
b. temperature
2. abdominal examination
a. inspection: incision site(s) if any
b. auscultation: bowel sounds hyperactive or hypoactive
c. palpation: tenderness, guarding, masses
3. pelvic examination
a. Uterus: tender, enlarged, masses, fixed or mobile; pain on cervi- cal manipulation
b. adnexa: masses, tenderness
d. laboratory
1. Cervical culture if fever, uterine or adnexal tenderness is present (gonorrhea, Chlamydia)
2. Urinalysis and culture if there are signs of urinary tract infection
3. CBC, differential, sedimentation rate, and/or C-reactive protein if fever, tenderness
4. pregnancy test if uterus enlarged or with adnexal mass, signs of ectopic pregnancy present
e. treatment
as indicated by symptoms and diagnosis
f. Complications
1. hemorrhage
2. increased risk of ectopic pregnancy
3. perforation of bowel
4. pelvic inflammatory disease
5. Urinary tract infection syndrome
6. salpingitis
7. infection of incision site(s)
8. pelvic abscess
9. peritonitis
10. Bladder damage burns with electrocoagulation
11. Uterine perforation
12. posttubal ligation
13. regrets
g. Consultation/referral
1. Consultation/referral to surgeon for differential diagnosis and treatment of any problem
2. referral for mental health counseling if experiencing sexual mal- adjustment, regrets
h. follow-up
1. return for recheck after resolution of any complications
2. age-appropriate annual exam, including pap smear per asCCp guidelines
3. hysterosalpingogram to confirm tubal occlusion with essure at 3 months
See Bibliographies.
Websites: www.managingcontraception.com; www.essure.com
NOTES
1. emergency contraception is indicated for 120 hours; efficacy rates are based on pills taken within 72 hours.
2. Consult individual method package insert.
3. some concerns have been raised about the patch because of higher expo- sure to estrogen as compared to most birth control pills. fda labeling has been changed to indicate this (www.drugs.com/pro/depo-provera.html).
4. U.s. boxed warning: prolonged use of medroxyprogesterone con- traceptive injection may result in a loss of BMd. loss is related to the
duration of use and may not be completely reversible on discontinuation of the drug. the impact on peak bone mass in adolescents should be considered in treatment decisions. U.s. boxed warning: long-term use (i.e., > 2 years) should be limited to situations where other birth con- trol methods are inadequate. Consider other methods of birth con- trol in women with (or at risk for) osteoporosis. retrieved from www
.rxlist.com/depo_provera-drug.htm
5. K. M. Curtis, d. J. Jamieson, h. B. peterson, & p. Marchbanks (2010). adaptation of the World health organization’s medical eligibility criteria for contraceptive use for use in the United states. Contraception, 82(1), 3–9;
M. e. gaffield, & K. r. Culwell (2010, March). new recommendations on the safety of contraceptive methods for women with medical conditions: World health organization’s medical eligibility criteria for contraceptive use, fourth edition. IPPF Medical Bulletin, 44(1), 1–5.
6. new recommendations on the safety of contraceptive methods for women with medical conditions: World health organization’s medical eligibil- ity criteria for contraceptive use, fourth edition. IPPF Medical Bulletin, 44(1), 1–5.
7. the nfp guideline was developed by the late eleanor tabeek, rn, phd, CnM, and is used with her permission and that of her family. Updates for subsequent editions by nancy Keaveney, Bs, rn, Mary finnigan, Ba, Ma, and for this edition Melissa K. perez, Ms, rn, Whnp-BC, clinical instructor, W. f. Connell school of nursing, Boston College.
8. World health organization: hormonal contraceptive methods for women at high risk of hiV and living with hiV. recommendations concerning the use of hormonal contraceptive methods by women at high risk of hiV and women living with hiV 2014 guidance statement.