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Immediate postpartum tubal ligation
Immediate postpartum tubal ligation An intraumbilical JACOB Winter
R. Park,
approach
ROZIER,
M.D.
Florida
This is a review of 392 cases of immediate postpartum tubal ligations, performed without any deaths during a 6 year period. There were only minor complications (1.5 per cent) and, as yet, no failures have been reported. From the data the procedure seems to be safe and relatively fast and saves the patient a second anesthesia and operative procedure. There does not seem to be much comparison with laparoscopic tubal sterilization, since most authorities do not recommend this immediately post partum; however, the incisions are very comparable in site and location.
1 N THE PA s T FE w years, we obstetricians have become increasingly aware of patients’ demand for improved health services including sterilization. Whether these patients are made aware of this through population control groups, mass education campaigns, or increasing socioeconomic pressure in the middle-income class is not known, but most are no longer willing to accept the older indications (as recent as 1965) for sterilization.’ One can find many excellent comprehensive reports in the literature on indications, techniques, and results for puerperal sterilization.2-” A review of the cases during the past 6 years has been carried out since “immediate postpartum tubal ligation” was instituted in this completely private hospital serving a predominantly middle-class population cared for by 6 Board-certified or qualified obstetricians. The review in this paper should determine whether our new approach to immediate tubal ligation while the patient is still on the From the Department Gynecology, Winter Hospital.
of Obstetrics Park Memorial
delivery table is an improvement in total health care of the obstetric patient as compared to older time-honored methods2e5 or some of the more recent reports on laparosCOPY.8’ !’ Clinical
There were 392 immediate postpartum tubal sterilizations performed at Winter Park Memorial Hospital, a 278 bed general hospital, in the 6 years from January 1, 1965, through December 31, 1970. During this time, there were 5,054 deliveries registered. Tubal ligations following cesarean sections were not included in this review. Table I shows a comparison of the number of ligations to the number of deliveries done each year. It is interesting to note that permissiveness is showing up in obstetrics. In 1965, the incidence of tubal ligations to deliveries was 1:22 or 4.4 per cent. Since the coming of abortion on demand, in 1970, the incidence of tubal ligation rose to 1: 8 or 11.3 per cent. In Table II, the average age was 31.8 years and the average parity was 3.9. In 1965, at the beginning of this study, the average age was 34 years and the average parity was 5.
and
Presented at the Thirty-fifth Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Hot Springs, Virginia, February 4-7, 1973. Reprint requests: Jacob R. Rorier, 255 North Lakemont Ave., Winter Florida 32789.
material
Operative
procedure
In 1965, it was decided that all postpartum tubal ligations would be done immediately after delivery provided the baby was in guod
M.D., Park,
226
Volume Number
117 2
Postpartum
condition. The fact that all patients were delivered of their infants under general anesthesia gave impetus to this conclusion, since an additional general anesthesia 24 to 48 hours later seemed to increase the patient’s gaseous distention and discomfort and also to increase the hospital stay beyond the average 5 day period. Immediately after perineal repair, the bladder was catheterized if this had not been done before delivery. Delivery drapes were removed, and the patient was placed supine on the table, prepared, and redraped, exposing the umbilicus. The umbilicus is usually flattened out or most of the dimpling is absent immediately post partum. While the patient is receiving intravenous lactated Ringer’s solution with one ampule of oxytocin” added, a 2 cm. intraumbilical crescent-shaped incision is made down to the fascia with a No. 15 blade. Actually, this incision will be intraumbilical when postpartum involution has taken place. It is virtually invisible, and the patient will be grateful for not having a larger midline incision in this day of hip huggers and bikinis. The fascia is picked up with small mosquito hemostats and opened transversely; in like manner, the peritoneum is opened. The fundus of the uterus is felt firm beneath the incision and can be moved from side to side to expose each cornu of the uterus with the attached Fallopian tube. By using 2 Lahey goiter retractors, the tube can be exposed and grasped with a Babcock forceps, identified, and ligated. The peritoneum is closed with 4-O absorbable suture, the fascia is closed with two 3-O nonabsorbable sutures, and the skin is closed with 2 absorbable subcuticular sutures. A one-inch plastic bandage will usually cover the operative incision very well. The Pomeroy procedure was used in all cases. No pain-relief medication is usually needed other than the routine postpartum analgesia. Analysis
of the
The data in Table II. Morbidity *Pito&,
Parke,
data
of the 392 cases are presented was noted Davis
& Co.,
in 5 cases in which Detroit,
Michigan
48232.
Table I. Summary from
1965 through
tubal ligation
of 392 tubal 1970
Year
Total delivcries
Total ligations
1965 1966 1967 1968 1969 197(!
757 775 815 880 920 907
34 53 54 60 88 103
1:22 1:14 1: 15 1:14 1:lO i:a
392
1:13
Total
5,054
227
ligations
Tubal ligations to deliveries
Percentage per year 4.4 6.8 6.6 6.8 9.6 11.3 7.7
there were minor temperature elevations of 100.4’ to 100.6’ F. and lasted only one day during postpartum stay in the hospital. These elevations were unexplained by clinical or laboratory findings and did not prolong the hospitalization of the patient or require further medication. Eighty-six per cent of the sterilizations were indicated because of multiparity, and the remaining 14 per cent, because of various medical, obstetric, or psychiatric reasons. These figures compare favorably with those of some recent reports.Z-4 Complications of rather mild cystitis occurred in 5 patients (1.2 per cent) . None of these cases was included in the abovereported morbidity and did not prolong the patient’s hospitalization. The hospital stay of 4.6 days is not significantly increased and compares very favorably with the average stay of 4.5 days, during 1970, of postpartum stay without operation. Comment McElin and associates,z reported 91.2 per cent, Hibbard’ reported 77 per cent, and Prystowsky and Eastman5 recorded 76.6 per cent of tubal sterilizations performed during the first 24 to 48 hours post partum. None was reported as immediate postpartum sterilization. Study of the data reveals reduction in cost to the patient, increased safety for the patient, effectiveness of the operative procedure, plus the saving of time for the patient, the hospital, the anesthesiologist, the nursing staff, and, in no small way, the obstetrician.
228
Septen~ber Am. J. Obstet
Rozier
Table II. Totals of data on immediate through Total ligations
Parity
391
3.9
‘Average
postpartum
1970
hospital
sterilization
from 1965
-
Morbidity 5 Cases,
Indication 1.2%
86% 14%
stay was 4.5 days
in 1970.
(Multiparity) (Other)
This procedure adds very little time (19.07 minutes) to a delivery. It also negates the necessity of a scheduling at a later time when it would take at least an hour5 to redress, scrub, and complete a separate procedure. The procedure seems safe with only a 1.2 per cent incidence of relatively mild cystitis. No major complications immediately postoperatively or during the 6 years of this study have been reported. We realize that the majority of our patients are young and healthy and, for the most part, have received adequate prenatal care for at least 6 months. These patients would not be predisposed to having the same complications as patients the larger clinics have reported.” Therefore, some of the data are not comparable, but they should be valuable to most obstetricians in private practice. Effectiveness is rather obvious since no failures have been reported up to the present time. We realize that this is a short period of time, and some5 have reported a failure as long as 90 months later which unfortunately turned out to be an obstetric death. We are sure that the law of averages will catch up with us in the future, and we will probably have some failures, hopefully nonfatal.
15, 19i3 Gynecol.
--
Complications 5 Cases,
1.2%
Average postoperatiue days in hospital*
Average age (wars)
4.6
31.8
Average operating
time (min.) 19.07
Comparing this procedure with laparoscopic sterilization, neither Steptoe” nor Cohen: recommends immediate postpartum sterilization by the laparoscope. Steptoe recommends waiting at least 8 weeks post par-turn. Keith and colleagues,s however, have carried out tubal sterilization in the puerperium in 167 cases, encountering hypotension as a complication in 39 (23 per cent) . At an earlier date,” 45 patients underwent puerperal tubal sterilization by laparoscopy, with hypotension again experienced as a complication and with an average operating time of 36 minutes. Having done approximately 200 laparoscopic procedures during the past 12 to 15 months, the attending staff members would be very reluctant if they had to punch a trocar through the lower abdominal wall of a recently delivered patient. Consequently, we intend to heed the advice of Steptoe” and Cohen’ and limit sterilization by laparoscopy to at least 2 to 3 months post partum. The entire attending staff is satisfied with this new approach to immediate postpartum tubal sterilizations and intends to continue to use this procedure.
REFERENCES
The American College of Obstetricians and Gynecologists: Manual of Standards in Obstetrics and Gynecology Practice, ed. 2, Chicago, 1965, American College of Obstetricians and Gynecologists. McElin, T. W., Buckingham, J. C., and Johnson, R. E.: AM. J. OBSTET. GYNECOL. 97: 479, 1967. Bopp, J. R., and Hall, D. G., III: Obstet. Gynecol. 35: 760, 1970. Hibbard, L. T.: Calif. Med. 107: 504, 1967.
5. 6. 7.
8. 9.
Prystowsky, H., and Eastman, W. J.: J. A. M. A. 158: 463, 1955. Steptoe, P. C.: Laparoscopy in Gynecology, London, 1967, E. & S. Livingstone, Ltd. Cohen, M. R.: Laparoscopy, Culdoscopy and Gynecography, Philadelphia, 1970, W. B. Saunders Company. Keith, L., Webster, A., and Lash, A.: Int. Surg. 56: 325, 1970. Keith, L., Houser, K., Webster, A., and Lash, A.: J. Reprod. Med. 6: 133, 1971.
Volume Number
117 2
Postpartum
Discussion (mcial Guest), Charleston, South Carolina. Having trained under a more rigid system when conservatism ruled the day, I am impressed by the rapid evolution which has occurred in puerperal sterilization. It has been less than 35 years since the first series of cases were reported in this country. All the patients in the first series underwent the operation for grave medical or eugenic conditions. Since that report, improvements in technique, better prenatal care, more appropriate anesthesia, and better screening have contributed to the great reduction in morbidity and mortality rates. These same advances have also eliminated almost all of the original medical indications for sterilization, as there are very few medical complications which cannot be safely managed throughout a pregnancy today. In addition, socioeconomic and legal pressures have also played a prominent role in the evolution of female sterilizations. Today, a general concern for overpopulation and a trend toward smaller families have made the role of tubal ligation more important as a simple and effective method of family control and account for its increasing incidence. Liberalization of our laws is also a contributing factor and, now, in many areas a genuine desire for sterilization is all that is required to constitute an indication. Dr. Rozier’s series of 392 cases, with the procedure performed immediately postpartum with the patient still on the delivery table, represents another simplification and improvement of this popular procedure. The low incidence of morbidity and lack of any major complication attest to the safety of the procedure. In Charleston, South Carolina, most puerperal sterilizations are performed in either the Medical University Hospital or Roper, a community hospital. At the University Hospital, the periumbilical “plastic bandage” incision has been used for the past several years, and approximately one third of the patients now have the operation immediately after delivery. Spinal or epidural anesthesia is administered by the obstetrician. Most patients are discharged after 24 hours. Presently, at Roper, sterilizations are not performed in the delivery room but in an operating room, usually within 24 hours post partum. Most of the staff are now using the periumbilical incision. All of us know the problems involved in scheduling postpartum sterilizations. It is often difficult to get these cases worked into a busy operating DR.
ARMSTEAD
BERT
PRUITT,
JR.
tubal
ligation
229
schedule, and a delay of several hours is not unusual. I feel Dr. Rozier’s method not only benefits the patient and results in a saving of time and money but also is very beneficial to the obstetrician’s busy schedule. Until some future date, when prostaglandins or another modality makes tubal ligation an outmoded procedure, it is the desire of obstetriciangynecologists to continue to improve and simplify this technique. I feel that Dr. Rozier’s approach does indeed represent an improvement. DR. WILLIAM H. RUDNICK (Official Guest), Sarasota, Florida. A few years ago, Dr. Allan Barnes, in discussing a paper on tubal sterilization, said that when a woman goes to bed with a man she puts her life at risk.l He rather graphically showed that if one million women went to bed with one million men for one year, with unrestricted parity and in the 35 to 44 year age group, the result would be a phenomenal 700,000 pregnancies with 400 maternal deaths. With that in mind, I am sure Women’s Liberation congratulates Dr. Rozier for sterilizing I of every 8 patients. It is generally accepted that puerperal tubal sterilization is a relatively safe procedure if performed within 48 hours after delivery. The author has elected to perform the operation at the time of delivery in an effort to save time and reduce hospital costs to the patient. Although he reports no anesthetic complications, I question the use of general anesthesia for vaginal delivery. Has he noted any increase in operative obstetrics such as difficult forceps delivery or any significant change in neonatal morbidity? Might it not be better to use inhalation analgesia for delivery and then subject the patient to general anesthesia? Or has he considered conduction anesthesia?, Inhalation of gastric contents is a frequent threat and indeed a cause of some 60 per cent of the maternal deaths associated with obstetric anesthesia.? Although anesthesia remains a lowgrade, potentially lethal factor in obstetrics, its lethality is enhanced not only by poor selection of anesthetic agents but also by poor selection of patients. Is the parturient who very often enters spontaneous labor within a few hours after a full meal properly prepared for elective general anesthesia at the time of delivery? In 1968, Mark and Webb3 reported the use of a disappearing incision for puerperal tubal sterilization. The incision closely approximates the type of transverse incision at the umbilicus as described by Mayo, in 1901, as an approach to
230
Rozier
repair of umbilical hernias. A transverse intraumbilical incision will allow retraction of the scar into the umbilicus when the abdominal wall returns to normal. There are two possibilities with the use of this incision: one is the development of infection, since the umbilicus is a difficult area to sterilize; the other is the likelihood of postoperative umbilical herniation. It is advisable to use this incision only when the umbilicus can be flattened out so that this area is thin and the operator need not work through a deep layer of subcutaneous fat. I caution its use in obese women and in heavy smokers with a persistent cough. Obviously, the chief advantage of such an incision is its cosmetic appeal to patients.
In summary, the author has presented two important points for us to consider: (1) prrformance of bilateral partial salpingectomy sterilization at the time of delivery, and (2 1 use of a disappearing incision. I feel his series of some 392 patients reflects, on the former, a smidgen of amazing luck and, on the lattter, a compassionate desire to preserve the appearance of the multiparous belly. REFERENCES
1, Haynes, D. M., and Wolfe, W. M.: AM. J. OBSTET. GYNECOL. 106: 1044, 1970. 2. Smith, B. E.: 111. Med. J. 133: 33, 1968. 3. Mark, P. M., and Webb, G. A.: Obstet. Gynecol. 32: 174, 1968.
R. Park,
approach
ROZIER,
M.D.
Florida
This is a review of 392 cases of immediate postpartum tubal ligations, performed without any deaths during a 6 year period. There were only minor complications (1.5 per cent) and, as yet, no failures have been reported. From the data the procedure seems to be safe and relatively fast and saves the patient a second anesthesia and operative procedure. There does not seem to be much comparison with laparoscopic tubal sterilization, since most authorities do not recommend this immediately post partum; however, the incisions are very comparable in site and location.
1 N THE PA s T FE w years, we obstetricians have become increasingly aware of patients’ demand for improved health services including sterilization. Whether these patients are made aware of this through population control groups, mass education campaigns, or increasing socioeconomic pressure in the middle-income class is not known, but most are no longer willing to accept the older indications (as recent as 1965) for sterilization.’ One can find many excellent comprehensive reports in the literature on indications, techniques, and results for puerperal sterilization.2-” A review of the cases during the past 6 years has been carried out since “immediate postpartum tubal ligation” was instituted in this completely private hospital serving a predominantly middle-class population cared for by 6 Board-certified or qualified obstetricians. The review in this paper should determine whether our new approach to immediate tubal ligation while the patient is still on the From the Department Gynecology, Winter Hospital.
of Obstetrics Park Memorial
delivery table is an improvement in total health care of the obstetric patient as compared to older time-honored methods2e5 or some of the more recent reports on laparosCOPY.8’ !’ Clinical
There were 392 immediate postpartum tubal sterilizations performed at Winter Park Memorial Hospital, a 278 bed general hospital, in the 6 years from January 1, 1965, through December 31, 1970. During this time, there were 5,054 deliveries registered. Tubal ligations following cesarean sections were not included in this review. Table I shows a comparison of the number of ligations to the number of deliveries done each year. It is interesting to note that permissiveness is showing up in obstetrics. In 1965, the incidence of tubal ligations to deliveries was 1:22 or 4.4 per cent. Since the coming of abortion on demand, in 1970, the incidence of tubal ligation rose to 1: 8 or 11.3 per cent. In Table II, the average age was 31.8 years and the average parity was 3.9. In 1965, at the beginning of this study, the average age was 34 years and the average parity was 5.
and
Presented at the Thirty-fifth Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Hot Springs, Virginia, February 4-7, 1973. Reprint requests: Jacob R. Rorier, 255 North Lakemont Ave., Winter Florida 32789.
material
Operative
procedure
In 1965, it was decided that all postpartum tubal ligations would be done immediately after delivery provided the baby was in guod
M.D., Park,
226
Volume Number
117 2
Postpartum
condition. The fact that all patients were delivered of their infants under general anesthesia gave impetus to this conclusion, since an additional general anesthesia 24 to 48 hours later seemed to increase the patient’s gaseous distention and discomfort and also to increase the hospital stay beyond the average 5 day period. Immediately after perineal repair, the bladder was catheterized if this had not been done before delivery. Delivery drapes were removed, and the patient was placed supine on the table, prepared, and redraped, exposing the umbilicus. The umbilicus is usually flattened out or most of the dimpling is absent immediately post partum. While the patient is receiving intravenous lactated Ringer’s solution with one ampule of oxytocin” added, a 2 cm. intraumbilical crescent-shaped incision is made down to the fascia with a No. 15 blade. Actually, this incision will be intraumbilical when postpartum involution has taken place. It is virtually invisible, and the patient will be grateful for not having a larger midline incision in this day of hip huggers and bikinis. The fascia is picked up with small mosquito hemostats and opened transversely; in like manner, the peritoneum is opened. The fundus of the uterus is felt firm beneath the incision and can be moved from side to side to expose each cornu of the uterus with the attached Fallopian tube. By using 2 Lahey goiter retractors, the tube can be exposed and grasped with a Babcock forceps, identified, and ligated. The peritoneum is closed with 4-O absorbable suture, the fascia is closed with two 3-O nonabsorbable sutures, and the skin is closed with 2 absorbable subcuticular sutures. A one-inch plastic bandage will usually cover the operative incision very well. The Pomeroy procedure was used in all cases. No pain-relief medication is usually needed other than the routine postpartum analgesia. Analysis
of the
The data in Table II. Morbidity *Pito&,
Parke,
data
of the 392 cases are presented was noted Davis
& Co.,
in 5 cases in which Detroit,
Michigan
48232.
Table I. Summary from
1965 through
tubal ligation
of 392 tubal 1970
Year
Total delivcries
Total ligations
1965 1966 1967 1968 1969 197(!
757 775 815 880 920 907
34 53 54 60 88 103
1:22 1:14 1: 15 1:14 1:lO i:a
392
1:13
Total
5,054
227
ligations
Tubal ligations to deliveries
Percentage per year 4.4 6.8 6.6 6.8 9.6 11.3 7.7
there were minor temperature elevations of 100.4’ to 100.6’ F. and lasted only one day during postpartum stay in the hospital. These elevations were unexplained by clinical or laboratory findings and did not prolong the hospitalization of the patient or require further medication. Eighty-six per cent of the sterilizations were indicated because of multiparity, and the remaining 14 per cent, because of various medical, obstetric, or psychiatric reasons. These figures compare favorably with those of some recent reports.Z-4 Complications of rather mild cystitis occurred in 5 patients (1.2 per cent) . None of these cases was included in the abovereported morbidity and did not prolong the patient’s hospitalization. The hospital stay of 4.6 days is not significantly increased and compares very favorably with the average stay of 4.5 days, during 1970, of postpartum stay without operation. Comment McElin and associates,z reported 91.2 per cent, Hibbard’ reported 77 per cent, and Prystowsky and Eastman5 recorded 76.6 per cent of tubal sterilizations performed during the first 24 to 48 hours post partum. None was reported as immediate postpartum sterilization. Study of the data reveals reduction in cost to the patient, increased safety for the patient, effectiveness of the operative procedure, plus the saving of time for the patient, the hospital, the anesthesiologist, the nursing staff, and, in no small way, the obstetrician.
228
Septen~ber Am. J. Obstet
Rozier
Table II. Totals of data on immediate through Total ligations
Parity
391
3.9
‘Average
postpartum
1970
hospital
sterilization
from 1965
-
Morbidity 5 Cases,
Indication 1.2%
86% 14%
stay was 4.5 days
in 1970.
(Multiparity) (Other)
This procedure adds very little time (19.07 minutes) to a delivery. It also negates the necessity of a scheduling at a later time when it would take at least an hour5 to redress, scrub, and complete a separate procedure. The procedure seems safe with only a 1.2 per cent incidence of relatively mild cystitis. No major complications immediately postoperatively or during the 6 years of this study have been reported. We realize that the majority of our patients are young and healthy and, for the most part, have received adequate prenatal care for at least 6 months. These patients would not be predisposed to having the same complications as patients the larger clinics have reported.” Therefore, some of the data are not comparable, but they should be valuable to most obstetricians in private practice. Effectiveness is rather obvious since no failures have been reported up to the present time. We realize that this is a short period of time, and some5 have reported a failure as long as 90 months later which unfortunately turned out to be an obstetric death. We are sure that the law of averages will catch up with us in the future, and we will probably have some failures, hopefully nonfatal.
15, 19i3 Gynecol.
--
Complications 5 Cases,
1.2%
Average postoperatiue days in hospital*
Average age (wars)
4.6
31.8
Average operating
time (min.) 19.07
Comparing this procedure with laparoscopic sterilization, neither Steptoe” nor Cohen: recommends immediate postpartum sterilization by the laparoscope. Steptoe recommends waiting at least 8 weeks post par-turn. Keith and colleagues,s however, have carried out tubal sterilization in the puerperium in 167 cases, encountering hypotension as a complication in 39 (23 per cent) . At an earlier date,” 45 patients underwent puerperal tubal sterilization by laparoscopy, with hypotension again experienced as a complication and with an average operating time of 36 minutes. Having done approximately 200 laparoscopic procedures during the past 12 to 15 months, the attending staff members would be very reluctant if they had to punch a trocar through the lower abdominal wall of a recently delivered patient. Consequently, we intend to heed the advice of Steptoe” and Cohen’ and limit sterilization by laparoscopy to at least 2 to 3 months post partum. The entire attending staff is satisfied with this new approach to immediate postpartum tubal sterilizations and intends to continue to use this procedure.
REFERENCES
The American College of Obstetricians and Gynecologists: Manual of Standards in Obstetrics and Gynecology Practice, ed. 2, Chicago, 1965, American College of Obstetricians and Gynecologists. McElin, T. W., Buckingham, J. C., and Johnson, R. E.: AM. J. OBSTET. GYNECOL. 97: 479, 1967. Bopp, J. R., and Hall, D. G., III: Obstet. Gynecol. 35: 760, 1970. Hibbard, L. T.: Calif. Med. 107: 504, 1967.
5. 6. 7.
8. 9.
Prystowsky, H., and Eastman, W. J.: J. A. M. A. 158: 463, 1955. Steptoe, P. C.: Laparoscopy in Gynecology, London, 1967, E. & S. Livingstone, Ltd. Cohen, M. R.: Laparoscopy, Culdoscopy and Gynecography, Philadelphia, 1970, W. B. Saunders Company. Keith, L., Webster, A., and Lash, A.: Int. Surg. 56: 325, 1970. Keith, L., Houser, K., Webster, A., and Lash, A.: J. Reprod. Med. 6: 133, 1971.
Volume Number
117 2
Postpartum
Discussion (mcial Guest), Charleston, South Carolina. Having trained under a more rigid system when conservatism ruled the day, I am impressed by the rapid evolution which has occurred in puerperal sterilization. It has been less than 35 years since the first series of cases were reported in this country. All the patients in the first series underwent the operation for grave medical or eugenic conditions. Since that report, improvements in technique, better prenatal care, more appropriate anesthesia, and better screening have contributed to the great reduction in morbidity and mortality rates. These same advances have also eliminated almost all of the original medical indications for sterilization, as there are very few medical complications which cannot be safely managed throughout a pregnancy today. In addition, socioeconomic and legal pressures have also played a prominent role in the evolution of female sterilizations. Today, a general concern for overpopulation and a trend toward smaller families have made the role of tubal ligation more important as a simple and effective method of family control and account for its increasing incidence. Liberalization of our laws is also a contributing factor and, now, in many areas a genuine desire for sterilization is all that is required to constitute an indication. Dr. Rozier’s series of 392 cases, with the procedure performed immediately postpartum with the patient still on the delivery table, represents another simplification and improvement of this popular procedure. The low incidence of morbidity and lack of any major complication attest to the safety of the procedure. In Charleston, South Carolina, most puerperal sterilizations are performed in either the Medical University Hospital or Roper, a community hospital. At the University Hospital, the periumbilical “plastic bandage” incision has been used for the past several years, and approximately one third of the patients now have the operation immediately after delivery. Spinal or epidural anesthesia is administered by the obstetrician. Most patients are discharged after 24 hours. Presently, at Roper, sterilizations are not performed in the delivery room but in an operating room, usually within 24 hours post partum. Most of the staff are now using the periumbilical incision. All of us know the problems involved in scheduling postpartum sterilizations. It is often difficult to get these cases worked into a busy operating DR.
ARMSTEAD
BERT
PRUITT,
JR.
tubal
ligation
229
schedule, and a delay of several hours is not unusual. I feel Dr. Rozier’s method not only benefits the patient and results in a saving of time and money but also is very beneficial to the obstetrician’s busy schedule. Until some future date, when prostaglandins or another modality makes tubal ligation an outmoded procedure, it is the desire of obstetriciangynecologists to continue to improve and simplify this technique. I feel that Dr. Rozier’s approach does indeed represent an improvement. DR. WILLIAM H. RUDNICK (Official Guest), Sarasota, Florida. A few years ago, Dr. Allan Barnes, in discussing a paper on tubal sterilization, said that when a woman goes to bed with a man she puts her life at risk.l He rather graphically showed that if one million women went to bed with one million men for one year, with unrestricted parity and in the 35 to 44 year age group, the result would be a phenomenal 700,000 pregnancies with 400 maternal deaths. With that in mind, I am sure Women’s Liberation congratulates Dr. Rozier for sterilizing I of every 8 patients. It is generally accepted that puerperal tubal sterilization is a relatively safe procedure if performed within 48 hours after delivery. The author has elected to perform the operation at the time of delivery in an effort to save time and reduce hospital costs to the patient. Although he reports no anesthetic complications, I question the use of general anesthesia for vaginal delivery. Has he noted any increase in operative obstetrics such as difficult forceps delivery or any significant change in neonatal morbidity? Might it not be better to use inhalation analgesia for delivery and then subject the patient to general anesthesia? Or has he considered conduction anesthesia?, Inhalation of gastric contents is a frequent threat and indeed a cause of some 60 per cent of the maternal deaths associated with obstetric anesthesia.? Although anesthesia remains a lowgrade, potentially lethal factor in obstetrics, its lethality is enhanced not only by poor selection of anesthetic agents but also by poor selection of patients. Is the parturient who very often enters spontaneous labor within a few hours after a full meal properly prepared for elective general anesthesia at the time of delivery? In 1968, Mark and Webb3 reported the use of a disappearing incision for puerperal tubal sterilization. The incision closely approximates the type of transverse incision at the umbilicus as described by Mayo, in 1901, as an approach to
230
Rozier
repair of umbilical hernias. A transverse intraumbilical incision will allow retraction of the scar into the umbilicus when the abdominal wall returns to normal. There are two possibilities with the use of this incision: one is the development of infection, since the umbilicus is a difficult area to sterilize; the other is the likelihood of postoperative umbilical herniation. It is advisable to use this incision only when the umbilicus can be flattened out so that this area is thin and the operator need not work through a deep layer of subcutaneous fat. I caution its use in obese women and in heavy smokers with a persistent cough. Obviously, the chief advantage of such an incision is its cosmetic appeal to patients.
In summary, the author has presented two important points for us to consider: (1) prrformance of bilateral partial salpingectomy sterilization at the time of delivery, and (2 1 use of a disappearing incision. I feel his series of some 392 patients reflects, on the former, a smidgen of amazing luck and, on the lattter, a compassionate desire to preserve the appearance of the multiparous belly. REFERENCES
1, Haynes, D. M., and Wolfe, W. M.: AM. J. OBSTET. GYNECOL. 106: 1044, 1970. 2. Smith, B. E.: 111. Med. J. 133: 33, 1968. 3. Mark, P. M., and Webb, G. A.: Obstet. Gynecol. 32: 174, 1968.