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Recommendations for Contraceptive Use |
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Female Sterilization |
Q.1. When can female sterilization be
performed?
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| a) Interval? Female sterilization can be performed any time the provider is reasonably sure a woman is not pregnant, for example, during the
seven days which begin with the onset of menses (days one through seven of the menstrual
cycle). |
a) Pregnancy is considered a
category D (delay the procedure until the condition is corrected) by the World Health
Organization (WHO) for performing female sterilization. While medically there does not
exist contraindications for performing a female sterilization during early pregnancy, the
perception is that the sterilization procedure has failed. Clients should be refused
sterilization if an early pregnancy cannot be ruled out.
- World Health Organization. Improving
access to quality care in family planning: medical eligibility criteria for contraceptive
use. Geneva: WHO, 1996.
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| b) Postpartum? (early postpartum)
Sterilization can be performed within the first seven days
postpartum, preferably within 48 hours after delivery.
The procedure should be delayed in the presence of certain
conditions (see WHO Medical
Eligibility Criteria).
(late postpartum)
Sterilization can also be performed postpartum once the
uterus is fully involuted. |
b-d) From the surgical
perspective, minilaparotomy performed within 48 hours after vaginal or cesarean delivery
is easier than and as safe and effective as interval sterilization. Because the uterus is
enlarged immediately postpartum, the fallopian tubes are nearer the abdominal wall, and
can be reached easily during the first 48 hours after delivery. Approximately two days
postpartum the uterus begins to involute and by two weeks is within the true pelvis. Thus,
after 48 hours postpartum, more care is required if sterilization is to be performed as
the uterus becomes less accessible from the subumbilical incision and its position in the
abdomen may be difficult to ascertain. The uterus is still accessible for up to seven
days, but may require a slightly lower incision.
- World Health Organization, Task Force
on Female Sterilization, Special Programme of Research, Development and Research Training
in Human Reproduction. Mini-incision for post-partum sterilization of women: a
multicenter, multinational prospective study. Contraception 1982;26:495-503.
- Cunningham FG, MacDonald PC, Leveno
KJ, Gant NF, Gilstrap LC. The puerperium. In: Williams Obstetrics. 19th ed. Norwalk, CT:
Appleton and Lange, 1993:459-73.
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| c) Post cesarean-section? Female sterilization can be performed at the same time as a
cesarean section, or within seven days (preferably within 48 hours) post-cesarean, as long
as the woman is stable.
The procedure should be delayed in the presence of certain
conditions (see WHO Eligibility
Criteria).
Sterilization can also be performed postpartum once the
uterus is fully involuted.
d) Postabortion?
Sterilization can be performed concurrently with a
medically safe induced abortion, or within seven days postabortion, if you are sure the
woman is free of infection.
In the context of postabortion care, where it is possible
that an unsafe abortion has occurred, female sterilization should not be performed unless
the provider is sure the woman is free from infection. |
b-d) It has been recent practice
to avoid doing female sterilization after 48 hours postpartum because of a concern about
increased infection. Because bacteria are present in the endometrial cavity and fallopian
tubes, prophylactic antibiotics are recommended when female sterilization is performed
beyond postpartum day three.
- Laros RK Jr., Zatuchni GI, Andros GJ.
Puerperal tubal ligation morbidity, histology, and bacteriology. Obstetrics and Gynecology
1973;41:397-403.
Severe pre-eclampsia/eclampsia, premature rupture of
membranes, sepsis or indication of infection, severe hemorrhage, and severe trauma to the
genital tract or uterine rupture or perforation are contraindications to female
sterilization and the procedure should be delayed until the condition is resolved.
- World Health Organization. Improving
access to quality care in family planning: medical eligibility criteria for contraceptive
use. Geneva: WHO, 1996.
The uterus is usually fully involuted four weeks after
delivery, although it may take six weeks or longer in some cases. For women who are not
breastfeeding and are therefore at some risk of pregnancy before six weeks postpartum, if
the uterus is fully involuted, female sterilization at four weeks postpartum can be safely
provided. If the uterus is not fully involuted, this may be a sign of infection or
incomplete resolution of postpartum healing and female sterilization should be delayed.
- Hatcher RA, Kowal D, Guest F, Trussell
J, Stewart F, Stewart G, et al. Voluntary Surgical Contraception. In: Contraceptive
Technology International. Atlanta: Printed Matter, 1989:59-64.
In the absence of complications, female sterilization can
be performed at the same time as the abortion.
- World Health Organization. Improving
access to quality care in family planning: medical eligibility criteria for contraceptive
use. Geneva: WHO, 1996.
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| Note: If the woman intends to breastfeed her infant, local anesthesia
is preferred over general anesthesia to minimize interruption of the early breastfeeding
pattern and infant exposure to the anesthetic agent. |
General anesthesia may affect
lactation by delaying the start of breastfeeding, because of the mother's recuperation
from the anesthesia and by hampering the infant's attempts to feed if the infant has
ingested some of the anesthetic agent in the milk. These negative effects on breastfeeding
are more pronounced when the sterilization is not performed immediately after delivery.
- Kennedy KI. Fertility, sexuality and
contraception during lactation. In: Riordan J, Auerback K, editors. Breastfeeding and
human lactation. Boston: Jones and Bartlett Publishing, 1993.
- Kennedy KI. Postpartum contraception.
Contraception 1996:10(1):25-42.
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