Author:

Adam Sachs MD 2018 HH Clinical Practice Reference: CPR.02.460

Postpartum Tubal Ligation on Labor and Delivery

• Scheduling Cases:
  • Weekdays:
    • Postpartum tubal cases should be booked to occupy one of the scheduled C-section time slots
  • Weekends/Holidays:
    • Ability to do cases depends on availability of nursing and anesthesia staff, and must be discussed with anesthesia attending in charge.
  • The timing of the procedure should be based on anesthetic and obstetric risk factors
    • Postpartum tubal ligation procedures should not be attempted at a time when they might compromise other aspects of patient care on the L&D unit.

• Patient Selection:
  • Postpartum tubal ligation is an elective procedure, and one should not proceed unless conditions are safe.
  • The anesthesiologist should assess the patient’s hemodynamic status and consider the anesthetic risk. The procedure should be delayed in patients with an unacceptable risk or patients who are not medically optimized for the procedure.
  • Patients who are to undergo tubal ligation should comply with the ASA guidelines for NPO status (NPO for at least 6-8 hours for solid foods, 2 hours for clear liquids).

• Anesthetic Management
  • Aspiration prophylaxis should be considered for all patients:
    • metoclopramide, H2 receptor antagonists, non-particulate antacid.
  • There is no conclusive data that any particular anesthetic technique results in better outcomes so the anesthetic plan should be based on both patient risk factors and the preferences of the anesthesia team, OB team & patient.
  • Although regional anesthesia may be recommended, rather than general anesthesia, due to the increased risks of aspiration, difficult or failed intubation, and postpartum
    hemorrhage (due to uterine relaxation for inhalational anesthetic agents) in this patient population, it is not required (as discussed above).
  • Because the anesthetic technique depends on patient preference, patient refusal is a contraindication to regional anesthesia.
  • If possible, indwelling labor epidural catheters should be used.
  • L&D staff should note on labor board if patient plans to have a tubal ligation.
  • Epidural catheter should be well-secured (consider tincture of benzoin and op-sites) when placed for labor if the patient plans to have a tubal ligation.
  • After delivery, the labor nurse will disconnect the epidural infusion, place a sterile plug on the end of the epidural catheter, and reinforce the op-site dressing if necessary.
  • The patient’s IV site should be left in place for the tubal ligation.
  • Consider dosing the epidural catheter with 3% chloroprocaine for the tubal ligation.
    • If the patient did not have a labor epidural, or had an incomplete epidural block for labor, consider a spinal anesthetic. Studies have shown an increased failure rate for reactivation of epidurals that have not been used for >10 hours, so this may also be a reason to elect spinal anesthesia.
      • A pencil point (Whitacre or Sprotte), 25 or 27 gauge spinal needle is recommended to decrease the risk of PDPH.
  • If regional anesthesia is refused or contraindicated, GA with a RSI is safest.
  • Standard monitoring (NIBP, spO2, EKG) in the PACU is required for all pts.

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Online Lecture:

Postpartum Tubal Ligation – OpenAnesthesia