Post-partum sterilization

POST-PARTUM

STERILIZATION

R. E. PFUETZE, M.D., (From

SAN JUAN, PUERTO RICO

Presbyter&w

the

Hospital)

D

URING the past twenty-eight months, 165 post-partum patients have been sterilized at the Presbyterian Hospital at San Juan. This is the largest series yet reported. Recently Adair and Brown reported 50 and Hewitt and Whitley 100 cases ; both groups were selected to insure freedom from infection and ease of operation. Our series has been relatively unselected. and done at varying intervals of time post-partum.

It is rarely convenient for us to operate immediately following delivery. For this reason the delay in almost every case was due to the convenience of time rather than the condition of the patient. Of the 165 patients, 127 were operated upon in the first twenty-four hours, 33 in the second twenty-four hours, 3 on the third day, one on the fourth day, and one on the fiith day, an eclamptic patient unconscious for four days and markedly toxic. The average length of time was 17.5 hours. Patients for whom sterilization was recommended were almost entirely ward patients. Private patients usually have access to and are more able or willing to use other less permanent forms of contraception. As soon as it became known that we were doing this type of sterilization, we were deluged with requests, and if for no other reason than self-defense, we have been very strict in the indications. These have been as varied as any given in previous papers, as is indicated in Table I. The greater the parity the less we require of good medical TABLE Heart disease Toxemias of pregnancy hypertension Syphilis Previous section Multiple pregnancies Pulmonary tuberculosis Recurrent pyelitis

and

I.

PRIMARY 4 6

INDICATIONS Contraception for future operations Markedly contracted pelves Epilepsy Schistosomiasis Chronic tropical lymphangitis Social and economic indications

4 1 63 p ii

9 8 3 : 56

indications. However, patients for whom sterilization was recommended due to multiple pregnancies or economic and social considerations had also as a major concurrent consideration the danger of additional pregnancies to their health and life. Due to the local conditions of gross over-population, increasing at the rate of 30,000 a year, or 9 per square mile per year, and the inability of the island to produce the bare necessities of life, the fear of endangering the future population was reduced to a minimum. 331

332

AMERICAN

.JOCJRSAI,

OF

OBSTETRICS

AK;D

GYNECOLOti1

the average parity at time The average age of all patients sterilized was 27.83; of operation was 5.04. The number of dead babies was 0.68 each, spontaneous abortions 1.0, and induced abortions 0.3. Nine patients had had previous lower abdominal Thirteen patients had a operations, and one had had drainage of the cul-de-sac. hemoglobin of 50 per cent or less at the time of operation. Seventeen patients were medically induced. Only two patients who would have been sterilized were refused operation llue to t,heir condition. Both were grossly infected on admission to the hospital anal ran a Two others were postponed three days because of long febrile post-partum course. fear of infection. Preoperative medication was given routinely to the patients. Three grains of nembutal were given one hour before operation and I,$ gr. of morphine with l$pio gr. The amounts varied of scopolamine three-fourths of an hour before operation. somewhat depending on the size of the patient. Almost none of the patients had any memory of leaving their room, and they usually slept through the entire operative procedure. Postoperatively only codeine and aspirin were given, and we have not noticed that these were given with much greater frequency than to other postpartum patients. Routinely, operations were done with local infiltration anesthesia of 0.5 per cent A short paramedian incision was made just below the level of the novocaine. umbilicus and the tubes brought into the field by hooking a finger over the round ligaments and rolling the uterus from side to side. In each case the tube was grasped in its midportion with an Allis forceps ant1 rlamped across the loop gently with a large Eelly forceps about 1 cm. from the Allis, A single tie of black silk was placed about the loop and usually an additional tie was placed through the mesosalpinx and around t.he tube in the tied-off loop of the tube. We endeavored to tie the first tie snugly but not so tightly as to rut the peritoneum. Closure of the abdomen was made with silk. Twenty or morf’ minutes were usually required to complete the procedure. Often we found a greater or less tlegree of edema of the Fallopian tubes, so that they resembled the round ligaments. Twice interns had attempted to tie the round ligament before attention was called to their error. On three occasions we have noticed thrombosed veins in the broad ligaments, but only once did these give later The gut is frequently not seen and only rarely does the patient cause trouble. There is a minimal disturbance of tissue trouble by pushing out, a, loop of gut. and no intra-abdominal bleeding. For economic reasons and convenience to the patient. other relatively minor operations may be easily done while the patient. is under the influence of .deep sedation. One umbilical ant1 two iuguinal hernias hare heen repaired at the same time, and all patients were afebrile postoperatively. On one occasion whrre symptoms were presented, an al~l~endecton~y was dour at, the time of of acute appendiciti? sterilization, in which case the patient was febrile the first four postoperative days. However, appendertomies would eventually lead to trouble and should certainly be discouraged at this time. Almost never do we do aup rxllloration, however slight. Using the morbidity standard ndvocaleti hy hhe American Committee on Maternal Welfare, the incidence of febrile morbidity of all patients was IS.3 per cent. Table IT shows rather definitely that the lowest morbidity is found in pat,ients operated TABLE

II.

HOURS POST PARTUJf

npou upon

in the first few hours within thp first twelve

SUWXARY PATIENTS OPERATED

after hours

OF MORBIDITY I 1

C~IIPAI~SOK

PATIENTS FEBKITX

delivery. The in&lence after delivery was 13.7

/

PER CXNT FEBRILE

in 73 patients per cent. This

operate~l compares

PFUETZE

:

POST-PARTUM

333

STERIIdZATION

favorably with all of our post-partum patients during this same period, of whom 18.6 per cent were morbid. However, if we compare it with only the multiparas not sterilized during this period, the comparison is not so favorable, as these patients had only a 9 per cent morbidity. We are unable to account for this, considering the lack of symptoms relative to the operation, but can attribute some of it to urinary tract infections abetted by the dehydration of the patient on the day of the operation. Only three patients remained in the hospital more than twelve days. One of these had phlebitis of the leg and was discharged on the thirty-fourth day. Another had phlebitis of the veins of the broad ligaments and was discharged on the twentyseventh day. In this case thrombosis of the veins of one side of the broad ligaments was observed at the time of operation and pain developed on this side first. These are the only two patients having thrombosis or phlebitis in this series. They were The third operated upon twelve and twenty-two hours after delivery, respectively. patient remained in the hospital fifteen days because of an attack of cholecystitis and cholelithiasis. None of the patients were at any time critically ill and in none could the infection be definitely attributed to the operation itself, although in the case of the patient having pelvic phlebitis, the sterilization was undoubtedly a large contributory factor. Of 11 patients -who had vaginal examinations or manipulations, 5 were febrile; however, the indication for manipulation may have contributed also. The average postoperative stay before discharge was 9.4 days. Of 4 patients complaining of some degree of pelvic tenderness several weeks following delivery, 3 had There were no wound infections and there were no been febrile in the hospital. deaths. Of the 165 patients sterilized, we know of 3 who have become pregnant again at intervals of three, four, and five months following operation. We reoperated upon two of the patients after the second delivery, removing the proximal portions of the Fallopian tube for examination and found that in one case a fistula had developed to the lumen of the proximal portion and in the other the atrophy of the tied-off portion was incomplete. Madlener suggested that the tie be made toward the outer portion of the tube, and findings in the two above cases would indicate this, as in both the tubes were tied quite close to the uterus. While in other patients on whom we have reoperated for other reasons and who have not become pregnant, the tie was found in the middle or outer portion with a section approximately 1 cm. long in which the tube was completely atrophied. No adhesions have been found either to the parietal or visceral peritoneum in any of these reoperated cases. CONCLUSIONS

The operation in general is a safe procedure, and easily accomplished with no unusual discomfort to the patient nor danger to her life. As has been pointed out by previous writers and as is borne out by these statistics, the sooner the operation is done following delivery the lower In addition, the operation is more will be the incidence of fever. easily done when the uterus is large and the intestines are held away from the incision by its mass. The greatest deterrent to pointing out the ease and safety of this operation is, that it may be too facilely performed on the post-partum mother who says, “no more babies, ” resulting in future sorrow and regret by the patient and an increased shortage of children in future generations. REFEREKCES ddcziT

Ibid.

39:

and

649,

Bmwn:

1940.

AK

J. OBST.

& GYNEC.

37:

473,

1939.

Hewitt

and

Whitley: