Immediate sequelae following tubal sterilization

CONTRACEPTION

IMMEDIATE

SEQUELAE FOLLOWING

TUBAL STERILIZATlON

*A Multicentre Study of the ICMR Task Force on Female Sterilization DIVISION OF REPRODUCTIVE BIOLOGY & FERTILITY INDIAN COUNCIL OF MEDICAL RESEARCH ANSARI NAGAR, NEW DELHI, INDIA

R.V. Bhatt' , C.S. Dawn', M.P. Gogoi3, A.N. Gupta', M.Kochar5 1; B.G. Kotwani6, M. Manuel', P. Misra* , F.S. Philips',S.S.Rao ,

INVESTIGATORS:

P. Rohtagi COORDINATORS

:

1.

11. 12. 13. 14. 15. 16.

11

, T. Seetha

A.D. Engineer K. Sanwal14

2. 3. 4. 5. 6. 7. 8. 9. 10.

CONTROL

14

12

, U.D. Sutaria

, I.P. Kambo

15

13

, U. Malhotra

15

,S.Mehta

15

,

, B.N. Saxena15, N.C. Saxena15, A.D. Taskar16

Baroda Medical College, Baroda Medical College, Calcutta Medical College, Gauhati Postgraduate Institute of Medical Education & Research, Chandigarh Kasturba Hospital, Delhi Maulana Azad Medical College, New Delhi Medical College, Madurai S.P. Medical College, Bikaner Institute of Obstetric & Gynaecology, Madras Institute for Research in Reproduction, Bombay G.S.V.M. Medical College, Kanpur Govt. Maternity Hospital, Hyderabad B.3. Medical College, Pune K.G. Medical College, Lucknow Indian Council of Medical Research, New Delhi Institute for Research in Medical Statistics, New Delhi

*The detailed version of this study has been published by the ICMR as a monograph entitled, "Collaborative Study on Sequelae of Tubal Sterilization", in 1983. Copies available from Dr. B.N. Saxena. Submitted for publication September 12, 1983 Accepted for publication November 22, 1983

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ABSTRACT

A total of 32,177 female sterilizations performed by different surgical procedures under different time scales were studied with reference to the effectiveness of the procedure and immediate, short-term and longterm complications arising out of the procedure. The results of immediate sequelae only are being reported in this article. Laparoscopic technique was employed in 7.1% of cases, culdotomy in 6.9% and minilaparotomyllaparotomy in the remaining 86% of cases. The findings indicate that minilaparotomy performed in the postpartum period is most suitable and safe for Indian women under existing conditions. Complications including mortality were least when the operation was performed as a minilaparotomy in the early postpartum Visceral injuries were maximum with the laparoscopic technique period. Mortality of interval sterilization was higher than that (10.45/1000). of postpartum sterilization (6.19/10,000 Vs 0.7/10,000) but this rate is lower than the current maternal mortality of the country (41.76/10,000). In view of the results obtained, it appears that minilaparotomy will continue to be "the method" of choice on a maas scale.

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INTRODUCTION

Tubal sterilization is one of the most widely accepted methods of family planning throughout the world. It forms an essential and major part of the National Family Planning Programmes of several countries. In India voluntary sterilization has shown a steadily increasing trend. lhe number of tubectomies performed in India rose from 0.539 million in 197374 to 2.062 million in 1976-77. In 1981-82, 2.214 million sterilization operations were performed (1). This widespread demand has encouraged both medical practitioners and researchers to evaluate existing methods of tubal occlusion and to develop new methods. The choice of approach and the method of tubal occlusion often depend upon the physician's prior training and skill, knowledge regarding the safety and effectiveness of the various techniques of ligation, their potential for reversibility and availability/ utilization of medical facilities. Sterilization, though a safe, simple and effective surgical procedure, is still associated with side-effects (2). In a vast country like India where facilities and medical practices vary from hospital to hospital, it is necessary to evaluate the complications assoaiated with tubal ligc?tion on a national basis. In view of the importance of the subject, the Indian CoL>ci: of Medical Research (ICMR) undertook a nationwide prospective study on shortterm and long-term sequelae of tubal sterilization.

MATERIALS AND METHODS

During the period from September 1976 to June 1978, a total of 32,177 sterilization cases were enrolled. Thirteen teaching hospitals located in different regions of the country participated in this collaborative study using standardized 'ommon protocol. The procedure adopted for sterilization, type of anaesthesia and concurrent surgery undertaken, if any, were left to the discretion of the operator. All centres recorded demographic details, obstetrical and medical data including menstrual history, procedure adopted for sterilization and complications on a uniform preceded -pro forma. The study was carried out in three components as follows: Component I :

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This included the demographic data and immediate postoperative complications up to the time of discharge of all women operated at the participating centres.

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component II:

The aim of this Component was to study the morbidity and mortality pattern up to 3 months after sterilization. 50% of Component I were included for Component II. Criteria for selection of this group was the availability of proper address, fixed and accessible residential limits agreed to by the centres, according to the availability of follow-up facilities. The follow-up was done twice, first at one month 2 7 days and second at three months + 15 days.

Component III:

The objective of this component was to evaluate the longterm sequelae of sterilization including menstrual abnormalities, pelvic inflammatory diseases, other gynaecological complications, psychological disorders and failure rates for a minimum period of two years. All women selected for Component II were included for Component III.

However only the immediate sequelae (Component I) are being reported in this article. Components II & III will be the subject of a separate report.

OBSERVATIONS

A.

AND RESULTS

Demographic Data-Analysis of the demographic characteristics of the acceptors showed that relatively younger women with low parity had come forward for sterilization (74.9% were below 30 years with average Women with at least one age at sterilization being 28.12 years). living male child had higher acceptance for sterilization, as compared to those who had no living son. The education of the acceptors and their husbands appeared to influence the acceptance as a result of which approximately 60% of the acceptors were either self-motivated or motivated by their Religion did not seem to hinder the acceptance of sterilihusbands. zation as the study sample consisted of fair representation from all religions in the population according to the 1971 census distribution. Acceptance was higher in the southern states as compared to other parts of the country, probably because of better motivation and higher female literacy status in these areas.

B.

Factors Influencing 1.

Prognosis

Route of Sterilization A total of 29,953 (93.1%) sterilizations were performed by abdominal,route and 2,224 (6.9%) by vaginal route. Of the abdominal operations, only 7.1% were by laparoscopy and the remaining 86% were by laparotomy (Table I). In 38 cases the primary procedure of sterilization (6 laparoscopies, 32 culdotomies) was abandoned and laparotomy had to be done either to complete the procedure or for management of complication of primary procedure.

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TABLE I:

ROUTE OF STERILIZATION

No. of cases

Primary Procedure

Laparotomy

Corrected Laparotomy after failure of primary figure** procedure

27657

27695

Laparoscopy

2296

6

2290

Culdotomy

2224

32

2192

Total

32177

38

32177

** for operations actually performed. 2.

Time of Sterilization It was thus observed that 44.5% of the sterilizationswere performed in the postpartum period, 3.1% in the postabortal period and 37.3% concurrent with caesarean section, Medical Termination of Pregnancies (MTPs) or during operations for ectopic gestation. In 15.1% of subjects, the procedure was performed in the interval period (Table II).

TABLE II: TIME Oh STERILIZATION

Time of sterilization

Postpartum Postabortal Concurrent: with a) Caesarean section b) Hysterotomy c) Ectopic d) MTP Interval Antenatal Total

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No.

Per cent

14308 1004 12005 2407 3468 77 6053 4848 12

44.47 3.12 37.31 7.48 10.78 0.24 18.81 15.06 0.04

32177

100.00

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The majority of the sterilizations performed in the postpartum, postabortal and as concurrent procedures with MTP were by laparotomy (98.4%, 93.7% and 64.1%, respectively). 3.

Anaesthesia

Used

Choice of anaesthesia was left to the discretion of the operator. Table III shows the details of different types of anaesthesia used for different surgical procedures. It is seen that the order of preference in the choice of anaesthetic was spinal (38.55%), local (31.56%) general (29.29%) and other anaesthesia (epidural and ketamine 0.6%). 4.

Post-operative

Antibiotics

Post-operative antibiotics were routinely administered as per institutional practise in 92.5% of cases. The commonest antibiotic combination used was streptopenicillin.

TABLE III: TYPE OF ANAESTHESIA

Anaesthesia used

Abdominal Laparotomy

Local

8597 (31.04)

Spinal

Epidural

Total

82 (3.74)

10155 (31.56)

10632 (38.39)

1687 (76.96)

12402 (38.55)

152 (0.55 )

Zl,

186 (0.58)

242 (11.04)

7221 (22.45)

6250 (22.57)

729 (31.84)

General without intubation

206 1 (7.44)

(OlO4)

Total:

Vaginal Culdotomy

1476 (64.46)

General with intubation

Ketamine

144 (6.57)

(O.:l)

27695

2290

(100.00)

Figures in parentheses

374

Route Laparoscopy

GIVEN

(100.00)

2206 (6.86)

4 (0.18)

7 (0.02)

2192 (100.00)

32177 (100.00)

indicate percentages

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CONTRACEPTION

C.

Operative

Complications

Complications during or following surgery occurred in 415 subjects. Out of these,265 women (8.24 per 1000) had immediate complications (within 24 hours of surgery) and in the remaining 150, the complicaThe tion occurred sometime during their hospital stay of one week. immediate complications are broadly classified in Table IV. 1.

Haemorrhage Excessive blood loss following the operation occurred in 85 cases (2.64 per 1000). In 18 cases (0.56 per 1000) it was due to the sterilization procedure, and in the remaining 67 cases, haemorrhage was on account of other concurrent surgery. These included 48 caesarean sections, 15 MTPs, 3 ectopic gestations and a concurrent myomectomy. In the 18 subjects in whom the haemorrhage had occurred as a result of the sterilization procedure, the route of sterilization had been by culdotomy in 6 cases, laparoscopy in 4 and laparotomy in 8 cases including one of minilaparotomy. Six subjects went into haemorrhagic transfusion.

TABLE IV: OPERATIVE

Complication

Total cases

COMPLICATIONS

Due to Sterilization

Due to other Surgery

Haemorrhage

85

18

67

Haematoma broad ligament

55

50

5

Shock

11

1

10

114

68

46

265

137

128

Visceral

injury

Total:

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shock and required blood

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2.

Broad Ligament Haematoma Out of 55 subjects in whom broad ligament haematoma had occurred, twelve were postpartum sterilizations and one was an interval minilaparotomy. The remaining 42 cases were those in <$hon,sLerilizations were performed concurrently with caesarean section (9 cases), hysterotomy (22 cases), suction evacuation (8 cases) and ectopic gestation (3 cases). Fifty-one of the haematomas were reported from one centre, where the operations were mainly performed by the staff undergoing training in tubectomy operations.

3.

Shock In addition to the six cases of haemorrhagic shock mentioned earlier, 5 other subjects also went into shock. Four of these were cases of concurrent ligations, while the fifth was a case of laparoscopic sterilization who went into shock when pneumoperitoneum was induced.

4.

Visceral Injuries

(Table V)

Visceral injuries occurred in 114 cases of which 58 were injuries to the uterus (50.88%); -21 of these were due to the sterilization procedure itself and the other 37 were sustained during concurrent surgery. Fifteen of the 21 uterine injuries attributable to the sterilization procedure occurred during laparoscopic sterilization (6.53 per lOOO), five occurred during laparotomy (0.18 per 1000) and one occurred during culdotomy (0.45 per 1000). When the uterine injuries encountered with laparoscopic sterilization were related to the timing of sterilization, it was seen that the rate was twice as high when the laparoscopic sterilization was performed in the postpartum period (13.51 per 1000) compared to the procedure performed either concurrently with MTP (6.35 per 1000) or as an interval procedure (5.75 per 1000). The other viscera which were injured were cervix (8 cases), bladder (8 cases), rectum (8 cases), intestine (8 cases), ovary (6 cases), fallopian tube (6 cases), round ligament (one case) and mesosalpinx (2 cases) of the total 114 visceral injuries; 68 were attributable to the sterilization procedure (2.11 per 1000). Analysis of all 68 visceral injuries attributable to sterilization according to the procedure adopted for the operation indicated that visceral injury rate was highest for laparoscopic ligation with a rate of 10.45 per 1000, followed by culdotomy ligation (7.64 per 1000) and least with laparotomy ligations (0.98 per 1000).

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TABLE V: SURGICAL COMPLICATIONS(VISCERAL

Route & time of sterilization (first procedure)

Total No. of women

Due to sterilization

INJURIES)

Due to other surgery

LAPAROTOMY Postpartum Post-abortal Con. caesarean Con. hysterotomy Con. ectopic Con. MTP Interval Antenatal

- (-)

14072 940 2407 3467 77 3861 2824 9

12(0.85) l(1.06) -(-I -(-) -(-) 8 (2.07) 6 (2.12) -(-)

33c8.55) 3c1.06) - (-)

27657

27CO.98)

39C1.41)

222 50 630 1391 3

5c22.52) -(-) 7(11.11) 12c8.63) -(-)

- (-)

2296

24c10.45)

6c2.61)

Postpartum Post-abortal Con. MTP Interval

14 14 1563 633

- (-)

- (-)

1171.43) g(5.76) 7c11.06)

- (-) l(O.64) - (-)

Total:

2224

17c7.64)

llO.45)

TOTAL:

32177

68c2.11)

(46 (NA))

Total:

- (-) 2cO.83) l(O.29) - (-)

LAPAROSCOPY

Postpartum Post-abortal Con. MTP Interval Antenatal Total:

- (-) 4c6.35) 2c1.44) - (-)

CULDOTOMY

Numbers in parentheses

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indicate rate/1000

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Similarly, when the sterilization was performed concurrently with suction evacuation for MTP, the number of visceral injuries seen were more with laparoscopy (Il.11 per 1000) as compared to culdotomy (5.76 per 1000) or laparotomy (2.07 per 1000). This difference was statistically significant (Pi.O.05). In the interval group, culdotomy ligations had a higher incidence (11.06 per 1000) of visceral injuries, particularly rectal Injury, than in operations performed either by laparoscopy (8.63 per 1000) or laparotomy (2.12 per 1000). In contrast, postpartum sterilizations (98.4 percent of which were performed by laparotomy) showed the lowest incidence of injuries to viscera (0.85 per 1000) compared to 22.52/1000 in laparoscopic cases, confirming that laparoscopy is not a suitable procedure for sterilization in the post-partum period. When the injuries were related to the training of the staff, interesting patterns were observed. Injuries were minimum (3.02 per 1000) at the hands of trained staff, somewhat higher (5.12 per 1000) for staff undergoing training and highest (10.03 per 1000) for trainees from outside the institution. 5.

Delayed Complications These were observed in 150 cases giving a rate of 4.66 per 1000 (Table VI). TABLE VI: DELAYED COMPLICATIONS

Delayed complications

SEPSIS

i) ii) iii) iv) v) vi)

Septicaemia Pelvic infection Pelvic peritonitis General peritonitis Pyogenic meningitis Urinary tract infection

Pulmonary embolism Pulmonary oedema Surgical emphysema Intestinal obstruction Paralytic ileus Thrombophlebitis Left ventricular failure Paroxysmal tachycardia Total:

378

No.

Deaths

124

8

7 22 4 7 2 82

6

2

4 1

4

1 4 2 11

2 1

150

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(i)

Sepsis

The main complication encountered was sepsis (3.85 per 1000), despite the fact that almost all women had received routine antibiotics postoperatively. Septicaemia occurred in 7 subjects of whom six were cases of obstructed labour and five of them died. The seventh was an MTP case in whom the uterus and bowel were perforated during surgery; she also expired. Patients who developed pelvic infection included 13 cases of laparotomy ligations (10 concurrent procedures, 2 postpartum and 1 post-abortal case) and 9 cases of culdotomy ligations (6 interval cases and 3 with concurrent MTP). The incidence of pelvic infection after culdotomy operations was nearly 10 times as high as that seen after laparotomy (4.11 per 1000 and 0.47 per 1000, respectively). In two of these sterilization Four cases developed pelvic peritonitis. had been performed concurrently with hysterotomy, one was a case of ectopic gestation, and the 4th was an interval culdotomy operation. Similarly, of the 7 cases who developed concurrent procedures. The commonest delayed complication was (82 cases, 2.55 per 1000) and 48 of them were 22 cases followed culdotomy ligations and the postpartum/interval laparotomy (11 cases) and Pyogenic meningitis

was also reported

general peritonitis,

5 were with

urinary tract infection (UTI) concurrent laparotomy procedures, remaining were associated with laparoscopy (1 case). in 2 women.

Excluding the 82 cases of UTI, it was seen that the incidence of sepsis was highest when sterilization was done by culdotomy. (ii)

Thromboohlebitis

Thrombophlebitis which occurred in 11 cases was associated with concurrent surgical procedures in 10 (6 caesarean sections, 1 ectopic gestation and 3 hysterotomies). The 11th was in a case of postpartum sterilization. (iii)

Wound Healing

The details of results regarding wound healing after one week of the procedure is shown in Table VII. Besides these, other complications as listed in Table VI were also observed, bringing the total incidence of complications to 4.66/1000.

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TABLE VII:

Wound Healing No.

Laparotomy Percent

25696

Healed Induration Granulation

WOUND HEALING

Laparoscopy Culdotomy No. Percent No.Percent

92.78

1611

70.35

1132

4.09

600

26.20

8

0.03

-

tissue

Stitch abscess

283

1.02

38

1.66

Dehiscence

149

0.54

14

0.61

79

0.29

1

0.04

333

1.20

26

1.14

15

0.05

-

.Dehiscence requiring resuturing Others (wound infections, etc.) Not applicable Total:

D.

Anaesthetic

27695

100.00

2290

100.00

Total No.Percent

29467

91 .56

8

0.36

1740

5.41

20

0.91

28

0.09

3

0.14

324

1.01

-

163

0.51

0.05

81

0.25

2160 98.54

-

1 -

-

359

1.12

-

_

15

0.05

2192 100.00 32177 100.00

Complications

Anaesthetic complications occurred in 66 (2.05 per 1000) women, 37 (1.15 per 1000) of these were immediate (Table VIII) and 29 (0.9 per 1000) were delayed complications (Table IX). Seven out of the 37 immediate complications In addition to this, 388 women experienced postturned out to be fatal. anaesthetic vomiting. With general aneasthesia, four women who were sterilized during caesarean section developed cardiac arrest and two of them died. Respiratory failure was observed in another two caesarean section cases resulting in death of both (one of them died of pulmonary collapse and the other due to laryngeal oedema). Shock occurred in 11 cases, only one of whom died after developing Mendelson's syndrome. The other ten cases associated with shock were all cases of concurrent caesarean section and all survived.

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TABLE VIII: IMMEDIATE ANAESTHETIC COMPLICATIONS

Type of Anaesthesia

No. of women

Complications No.Rate/ 1000

Local

10155

2

0.20

-

Spinal

12402

13

1.05

1

9427

21

2.23

4**

Epidural

186

1

5.38

-

Ketamine

7

Total:

32177

General (with or without intubation)

Cardiac arrest

Respiratory arrest

Pulmonary collapse

Cardio- Shock Apnoea respiratory arrest 2*

1*

1"

1

-37

1.15

*One case died.

1

5

1

-

12

-

11"

3

1

-

-

_

26

3

**Two cases died.

TABLE IX: DELAYED ANAESTHETIC COMPLICATIONS

Type of Anaesthesia

No.of women

Complications No.Rate/ 1000

Local

10155

7

0.69

-

1

Spinal

12402

12

0.97

9

2

9427

8

0.85

-

2 10.36

-

-

9

3

General (with or without intubation Others (Epidural, Ketamine) Total:

193*

32177

33

1.03

Neck regidity

Paresis

Paresthesia

Allergy

2

Respiratory infection

4

1

8

2

1

2

18

*Includes 186 epidural and 7 ketamine

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With spinal anaesthesia, there was one death due to cardiac arrest and 12 subjects (0.97 per 1000) went into shock, but all were revived, the majority being concurrent procedures. In addition, neck rigidity, paresis of limbs, hemiparesis and paresthesia were also observed in 12 cases. Out of a total of 10,155 women who were given local anaesthesia, only 9 women had developed complications, out of which two developed skin allergy and anaphylactic reaction was seen in 2 cases (0.39 per 1000). In the remaining five cases, the complication observed did not appear to be related to the anaesthesia (4 cases of respiratory infection, 1 case of hemiparesis in a hypertensive case).

E.

Mortality

Complications were encountered up to one week following sterilization in 485 cases (15.07 per 1000) and, of these, 23 were fatal, giving a mortality rate of 7.15 per 10,000 operations. Seven deaths were attributed to the anaesthesia administered (2.18 per 10,000) and 16 (4.97 per 10,000) occurred as a result of the operative procedure. 1.

Deaths Due to Anaesthesia

The single death which occurred after local anaesthesia was in a patient scheduled for MTP with laparoscopic sterilization under spinal MTP could not be completed on account of uterine perforation. anaesthesia. However, laparoscopic sterilization was performed and uterine perforation The patient was recalled after 12 days for MTP under local confirmed. anaesthesia but the patient went iuto .lnaphylactic shock and expired. On post-mortem examination, there were bilateral haematomas in the broad ligament, indicating that the anaesthetic solution had leaked into the parametrial tissue. Of the five deaths which occurred when general anaesthesia was administered, two were due to cardiac arrest, one followed pulmonary collapse and another was due to acute laryngeal edema. The 5th was a case of interval minilaparotomy, who developed Mendelson's syndrome and died 4 days later. The one death following spinal anaesthesia

2.

was due to shock.

Deaths Due to Operative Procedures

Of the 16 deaths attributable to the operative procedures, there was only one death in each of the postpartum and interval groups, while 14 deaths occurred where ligation was done concurrently with other procedures.

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The only death in the postpartum group occurred when sterilization was carried out immediately following manual removal of placenta in a The death which had patient who was already weak from loss of blood. occurred in the interval case was in a subject who developed general peritonitis after culdotomy ligation and died on the 22nd day in spite of treatment. Of the 14 deaths in the concurrent group, the fatal outcome could not be attributed to the sterilization procedure in any of the 11 caesarean section cases (5 cases of obstructed labour died of septicemia, 3 of pulmonary embolism, one woman with mitral stenosis of pulmonary edema, one accidental haemorrhage case died of coagulation failure and one case of placenta previa died of haemorrhagic shock). The remaining 3 deaths were associated with MTP (2 hysterotomies and 1 suction evacuation).

3.

Death Versus Time of Sterilization

Classifying the deaths according to the time of operation, only one death was noted to have occurred in 14,308 postpartum cases giving a mortality rate of 0.70 per 10,000 whereas mortality was 6.19 per 10,000 for interval The mortality was maximum with concases. All were uncomplicated cases. current ligations, 15.83 per 10,000. On further analysing the deaths, it was noticed that when suction evacuation was the concurrent procedure, the mortality rate was only 3.30 per 10,000 compared to hysterotomy (5.77 per 10,000) and caesarean section (62.33 per 10,000).

4.

Death Versus Route of Sterilization

Analysing the deaths by route of sterilization, 21 out of the 23 deaths occurred when the procedure was performed by laparotomy; however, 18 of them were complicated cases where the death could not be attributed to the sterilization procedure and two were deaths due to complications of the anaesthesia. No death occurred in cases of laparoscopic sterilization, though one death was indirectly attributable to this procedure (described in detail earlier). With culdotomy ligation, there was one death (4.55 per 10,000) in an uncomplicated interval case.

DISCUSSION

In this study, the choice of operative approach was left entirely to the individual operator and all three operative approaches have been practised; namely, laparotomy, culdotomy and laparoscopy. The laparoscopic technique was employed only in 7.1% of cases and culdotomy in 6.9%. Hence, minilaparotomy appeared to be the most widely used method employed for female sterilization. As regards the timing of sterilization, postpartum and concurrent procedures (with MTP/caesarean section, etc.) were more widely performed This may be because motivation was strong at this than interval procedures. time. Only 15.1% of procedures were performed in the interval period.

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In view of the results of the study, it seems that for many years to come, in this country at least, minilaparotomy will continue to be the method of choice as a procedure of female sterilization operation on a mass scale. The choice of anaesthetic is also important and spinal anaesthesia with its high incidence of shock and neurological sequelae should be avoided, as much as possible. In uncomplicated cases, local anaesthesia gives good results. This is in conformity with results from other studies, especially for minilaparotomy (3, 4). However, in view of the anaphylactic skin allergy and reactions observed, it is advised that sensitivity testing should precede its use in all cases and care should be taken to ensure that the drug does not enter the blood stream. The results of a multi-national study of WHO (6) as well as others (5) all confirm generally that the incidence of complication time of operationare greater with the laparoscopic approach.

at the

As more trained laparoscopists become available, laparoscopic sterilizations are becoming increasingly popular for interval cases and in the next decade may replace minilaparotomy for this group. Laparoscopic sterilization is however not suitable for postpartum cases and since it is postpartum cases which constitute the maximum number of sterilization operations performed in our country, the performance of postpartum minilaparotomy should be encouraged wherever and whenever possible.

REFERENCES

1.

Family Welfare

2.

CDC Document on Surgical Issued July 1979.

3.

Suprapubic minilaparotomy, uterine elevation Vitoon, 0.: technique: Simple, inexpensive and out-patient procedure for interval feamel sterilization. Contraception 10:251, 1974.

4.

Penfield, A.J.: Minilaparotomy 54:184, 1979. Obst. Cynae.

5.

Laparoscopic Mumford, S.D., Bhiwandiwala, P.P. and Chi, I.C.: and minilaparotomy female sterilization compared in 15,167 cases. Lancet 2, 1066, 1980.

6.

Minilaparotomy multi-national

Programme

in India, Year Book Sterilization

1981-82.

Surveillance,

for female sterilization.

or laparoscopy for sterilization: randomized study.

A multicentre,

WHO, Task Force on Female Sterilization, Special Programme of Research, Development and Research Training in Human ReproducAm. J. Obst. and Gynae., 143:645, 1982. tion.

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