This chapter should be cited as follows: This chapter was last updated:
Eisenberg, D, Glob. libr. women's med.,
(ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10145
May 2008

Puerperium

Postpartum Sterilization Procedures

David L. Eisenberg, MD
Section of Family Planning and Contraception, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA

INTRODUCTION

Sterilization following delivery during a patient's postpartum hospital stay is a convenient, effective, usually efficient, and cost-effective means of preventing future pregnancy. Procedures for performing tubal sterilization have become much more prevalent in recent years.  It has been estimated that more than 350,000 sterilization procedures are performed in the postpartum period annually.1  Four basic methods of postpartum sterilization are available: tubal surgery alone, tubal surgery at cesarean section, cesarean hysterectomy, and postpartum hysterectomy during initial hospital stay.   Barring significant disease of the internal female genitalia, elective postpartum sterilization is best carried out by tubal surgery shortly after delivery, not by hysterectomy.  Sterilization performed after vaginal delivery is generally via a minilaparotomy made in the periumbilical region whereas the abdomen is already open during a cesarean section through a low-transverse or low-vertical laparotomy.  Recently, a fifth method—laparoscopic tubal sterilizatoin in the postpartum period has also been proposed.2  However, the potential benefit of a laparoscopic approach over a minilaparotomy in the postpartum period has been called into question.3

PREOPERATIVE CONSIDERATIONS

Patient Preparation

As dicsussed in the chapter on Surgical Procedures for Tubal Sterilization (Sciarra), proper patient counseling and informed consent is of paramount importance prior to a postpartum sterilization procedure. There must be no contraindications to elective surgery. The decision for sterilization should be made on an entirely voluntary basis following appropriate discussion regarding risks, benefits, and alternatives.  The plan for postpartum sterilization should have been discussed and decided upon during the prenatal care period. Topics covered should include timing, techniques, side-effects, complications, long-term effects, and an emphasis on the irreversible nature of the procedures used for postpartum sterilization. The patient's partner should be included in the discussion, if practical, or at least the woman should be asked to impart the information to the partner. For completeness, the alternatives to female sterilization (i.e. reversible contraception, male sterilization) should also be mentioned.4, 5, 6 The counseling and decision to proceed with permanent sterilization should be appropriately documented in the prenatal record as well.7 

Tubal sterilization procedures are among the most frequent sources of litigation. Adequate informed consent with chart documentation of the points mentioned earlier, especially failure rate and the most usual complications, is essential.8 Some physicians and hospitals may require the patient and her husband to sign a sterilization permit as well as the usual consent for surgery.  If the patient is a recipient of public aid funding for healthcare it is necessary to satisfy state and federal regulations regarding consent for sterilization and possibly mandated waiting periods that can be up to 30 days.

 

Timing of the Procedure: A Labor & Delivery Team Approach

After a routine vaginal delivery without complications or during an uncomplicated cesarean delivery, tubal sterilization can generally be performed without difficulty.  However, in determining whether it is appropriate to continue with immediate postpartum sterilization requires consideration of the other demands of obstetric and anesthesia staff.  As this is an elective procedure, it should not be performed when it may divert the attention of anesthesia, obstetric, pediatric and nursing personnel from more acute and pressing concerns.  The whole labor and delivery team must be considered before the decision to proceed with immediate postpartum sterilization is acted upon versus possibly postponing.9  It is important that the obstetrician has educated the patient who desires postpartum sterilization about the potential need to postpone such a procedure given the limitations of the healthcare team.10  

Tubal sterilization may be done immediately following the completion of the vaginal delivery or after closure of the uterine incision during cesarean section. If not completed at the time of cesarean or in the first few hours after delivery, the procedure is delayed until an appropriate time is available.  This is generally completed within the first 48 hours after delivery. There are advantages to both immediate and delayed procedures, and factors in the choice include patient and physician preferences, and issues involving anesthesia, and hospital routines. The advantage of performing the tubal procedure at the time of cesarean section needs no further comment.

If there are any significant complications or potential problems at or immediately after delivery, the tubal procedure should be delayed, sometimes indefinitely. Concurrent medical, psychological, or neonatal conditions may also warrant deferment. Additionally, if any uncertainty regarding permanent sterilization is expressed by the patient or her spouse during or after labor and delivery, it is best to delay the procedure.

Discussing with the patient the options of immediate versus delayed procedures is helpful. Some patients or couples prefer to wait for 12–48 hours to be as certain as possible that the baby is healthy. Others want no future pregnancy under any foreseeable circumstance, and the procedure may be done at any time.

A single anesthetic procedure, avoidance of a second operative protocol and procedure, and shorter hospital stay all favor doing the tubal surgery on the day of delivery. Postoperative morbidity seems to be about the same regardless of the timing of the tubal surgery. It is important to remember that postpartum sterilization is an elective procedure and one should not proceed unless conditions are safe.11 

 

Anesthesia Considerations

The American Society of Anesthesiologist's Task Force on Obstetric Anesthesia published Practice Guidelines for Obstetric Anesthesia in 1999 that included discussion of postpartum sterilization.12  Though considered to be a small surgical procedure, tubal ligation can produce significant pain and cause physiologic changes similar to cesarean delivery due to manipulation and peritoneal stimulation.10  In the setting of tubal ligation at the time of cesarean, the patient should have adequate anesthesia.  Choice of anesthetic after vaginal delivery is usually to redose an existing epidural if the catheter is still in place and functioning.13  The anesthesia team must assess if the labor epidural catheter is functioning well-enough to provide adequate anesthesia for a postpartum tubal ligation.  If the patient did not receive epidural anesthesia during labor or it is not functioning, a spinal anesthetic may be appropriate.  Local infiltration into the abdominal wall and then into the mesosalpinx is a less common alternative and may be employed in the setting of inadequate conduction anesthesia in order to avoid a general anesthetic.10

It is extremely important that the patient who desires postpartum sterilization and is undergoing a routine vaginal delivery not have any solid oral intake at least 8 hours prior to delivery and immediate postpartum sterilization according to Practice Guidelines for Obstetric Anesthesia.  The same publication notes that small amounts of clear liquids may be consumed up to 2 hours before surgery.12  Given the decreased gastric emptying associated with pregnancy and the subsequent slowing of the intestinal tract during labor, patients are at very high risk of aspiration if general anesthesia is required during tubal ligation.12

 

TUBAL SURGERY

Anatomy & Surgical Approach

The uterus is still enlarged and raised out of the pelvis for several days to 3 weeks after delivery, making the tubes more accessible to abdominal surgical techniques and less attainable by vaginal routes. Therefore, almost all sterilization procedures in the early postpartum period are performed through abdominal incisions—generally minilaparatomy.1 However, with the ever-increasing use of minimally invasive surgical techniques some surgeons have begun using a laparoscopic approach.  Postpartum laparoscopic tubal sterilizations have been reported in the literature since the mid-1980s with the largest published series of such procedures described in 2007.2 Though the authors of this series concluded that postpartum laparoscopic sterilization may be superior to postpartum minilaparotomy, others have drawn attention to the possibility that this may not always be true in settings with less technical and/or anesthetic resources available.3 

The fallopian tubes may be larger and more edematous, and the mesosalpinx, as well as the broad ligament, often contains enlarged, tortuous blood vessels in the early postpartum period. These conditions may make surgical procedures on the tubes more difficult and provide a greater opportunity for bleeding problems to occur. It is extremely important to identify the tubes throughout their entire length before any intervention to ensure that the proper structure is being occluded or divided. Both adnexal regions should be thoroughly inspected for any abnormalities. Likewise, the uterus should be evaluated for any significant or unexpected gynecologic disease.

It is important to consider a woman’s past surgical and medical history in the decision to proceed with a postpartum tubal sterilization.  An abdominal approach may be extremely difficult in a woman with a history of multiple abdominal surgeries, intra-abdominal adhesive disease, repaired abdominal wall hernias, morbid obesity or history of pelvic inflammatory disease.  It may be better to consider a different form of permanent sterilization such as an interval hysteroscopic approach, however this will require instituting a method of contraception in the immediate postpartum period until the patient becomes a good interval tubal sterilization candidate.  A commonly prescribed long-acting reversible contraceptive method in this setting is depot medroxyprogesterone.  For further details on the laparoscopic and hysteroscopic procedures as well as postpartum sterilization refer to their respective chapters.  This chapter will focus on immediate postpartum sterilization procedures.

Preoperative laboratory studies should include evaluation of hemoglobin, hematocrit, and white blood cell count with differential. These studies may be obtained during labor in those patients who are to have immediate postpartum sterilization. Hospital regulations may require a recent electrocardiogram and/or blood chemistry profile, especially in those women with special medical situations or in those taking certain medications (e.g. steroids, diuretics).

A patient's bladder should always be emptied just before the sterilization procedure to minimize the risk of entering the bladder. An indwelling catheter is not necessary unless one is already in place or is advisable for other reasons (e.g., cesarean section, traumatic delivery). Other standard preoperative preparatory conditions must be met if sterilization is being performed as a separate procedure at a time other than immediately after delivery.

Methods

Given the size and location of the uterus immediately postpartum, an abdominal approach is the post preferred method for tubal sterilization.  A periumbilical transverse incision is often used when the tubal procedure is done soon after delivery and the level of the uterine fundus is near the umbilicus. It is cosmetically more appealing, and there is less bleeding and less postoperative discomfort. The procedure may take slightly longer if this type of incision is used, and the exposure for inspecting the uterus and adnexa is more limited. The other approach is through a vertical midline incision somewhere between the umbilicus and the symphysis pubis. The height of the fundus determines the specific location, as well as the possibility of using a preexisting lower abdominal incision.

Most physicians use an small, open laparotomy type of incision rather than laparoscopy unless the procedure has been delayed for more than several days and the uterus has decreased too much in size. There has been little enthusiasm or advantage shown for using the laparoscopic approach within the first 2 or 3 days after delivery. If laparoscopy is chosen as the postpartum technique, it should be performed only by physicians who have expertise in the method, because of uterine size and broad ligament vascularity.14, 15 As stated previously, there are physicians who feel that laparoscopic postpartum tubal sterilization is equivalent or better than the open minilaparotomy approach.2, 3  

Several procedures for interrupting the passage of the egg through the fallopian tube are popular.  (See the detailed descriptions of surgical techniques described in the chapter on Surgical Procedures for Tubal Sterilization)  Most often, a portion of the ligated tube is removed so that the cut ends will close over and separate. The Pomeroy method16 or its modifications remain the most commonly used tubal ligation procedures. A small loop in the tube is formed near the midportion by picking up the tube with a clamp. The loop is ligated at its base using an absorbable suture (Fig. 1); then a portion of the loop is excised. This is the simplest method, and if the cut ends and the surrounding mesosalpinx are carefully inspected for bleeding, complications are unusual. Some surgeons ligate the cut ends individually to ensure hemostasis. However, more inflammatory reaction and less likelihood of separation of the cut ends when dissolution of the suture occurs are the theoretical disadvantages of using more than a single catgut suture at the base of the loop.

Fig. 1. Pomeroy method for tubal sterilization. ( A) Forming loop of tube and ligating base. ( B) Site of tube excision. ( C) Cut ends before absorption of suture and separation.

Similar to the Pomeroy technique, the Parkland procedure is a method of partial salpingectomy for sterilization.  However, rather than ligation of a knuckle of tube followed by creation of a window in the mesosalpinx, the window is created first.  The  is performed by identifying an avascular section of the mesosalpinx (Fig. 2A) and creating a window in this region (Fig. 2B), below the tube, with Metzenbaum scisscors or a hemostat while elevating the tube with babcock clamps.  By opening the hemostat or scissors within the windo it can be stretched in parallel with the tubal lumen.  A 2-cm segment of the mid-portion of the tube is then ligated proximally and distally with separate 0 chromic, or plain gut, sutures (Fig. 2C).  The segment between the suture ligatures is then excised (Fig. 2D).  The Parkland method provides for immediate anatomic separation of the disconnected tubal segments unlike the Pomeroy technique.17, 18, 19

 

Fig. 2A. Identification of avascular region of mid-portion of tube.17







 

 Fig. 2B. Window through mesosalpinx is created below the tube.17








Fig. 2C. Rapidly-absorbable (O chromic or plain gut) sutures placed proximally & distally.17








 Fig. 2D. Ligated portion of tube excised.17

 

 

 

 

A similar but less effective method, that of Madlener, also involves forming a loop of tube, but a portion is not removed. Instead, the tube is crushed at the base of the loop and ligated with a nonabsorbable suture (Fig. 3A). Occlusion but not division of the lumen is achieved. Care must be taken to not make the ligature so tight as to cut through the tube. Failures are attributed mainly to fistula formation at the ligature site.

Fig. 3. ( A) Madlener method for tubal sterilization. ( B) Modified Irving tubal sterilization. ( C) Another modified Irving technique. Both cut ends are buried in the broad ligament.

In 1924, Irving described a technique of tubal sterilization at cesarean section.20 More adequate exposure of the uterus allows an easier approach for this method. A revision of this procedure was described in 1950.21 After cutting through the tube at the isthmic portion, the proximal end is buried into the posterior wall of the uterus. Others have modified this technique to include burying the distal end into the leaves of the broad ligament (Fig. 3B). This method takes longer, and there may be greater blood loss; however, the chances of tubal recanalization or pregnancy in the proximal stump are remote. Among these three methods, the least number of pregnancies have been reported with the Irving technique.

Other variations of tubal sterilization have been tried but never gained much popularity. The Irving method was modified to bury both cut ends into the broad ligament (Fig. 3C). Additionally, merely burying the fimbriated end of the tube in a pocket in the broad ligament (i.e. Aldridge technique) was thought to be a good temporary means of sterilization (Fig. 4A). Reversal by freeing the ends of the tubes was thought to be easily accomplished. Unfortunately, the rate of pregnancy after restoration was not as anticipated, especially if tubal or peritoneal infection occurred after the initial attempt at sterilization.

Fig. 4. ( A) Aldridge technique of tubal sterilization. ( B) Cornual resection of the tube for sterilization. ( C) Silastic band for tubal occlusion.

Cornual resection including an adjacent portion of the tube has also been described, but this procedure requires more exposure and results in greater blood loss (Fig. 4B).

The Oxford method of interposing the round ligament between the cut ends of the isthmic portion of the tube has never been prevalent in the United States, nor has the Uchida method of tubal resection at its ampullary portion been popular because of its complexity, potential for bleeding, and greater length of tubal resection.22 Another method of fimbriectomy following distal ligation with silk sutures attributed to Kroener also carries a high failure rate.

More recently, banding of the tube with nonabsorbable materials has gained popularity. Stainless steel clips and Silastic bands can be used to occlude the tubal lumina (Fig. 4C).23 Laparoscopy and open incisional techniques have both been used for application of these clips and bands in the postpartum period. Complications are minor; mild discomfort has been noticed at the site of occlusion. The effectiveness rate has been found to be very acceptable based on follow-up of patients for several years after application. Green and Laros give a complete description of most traditional and newer techniques in their monograph.14 With the advent of the Filshie clip, created by British obstetrician–gynecologist, Marcus Filshie, another tubal occlusion device was available for use at either interval laparoscopic or postpartum tubal sterilization (Fig. 5). A recent pilot study published by Kohaut et al. noted that besides the proven safety and efficacy of the Filshie clip, it may be superior to other postpartum tubal sterilization methods due to its perceived ease of application and decreased need for significant dissection or exteriorization of the tube.  The Filshie clip applicator for postpartum sterilization as pictured in Figure 5 is similar to the laparoscopic applicator, but is shorter in length.24

 
Fig. 5. Minilap applicator and Filshie clip. From Kohaut BA, Musselman BL, Sanchez-Ramos L et al., Contraception, 2004; 69:267-4024, copyright 1997, with permission from Elsevier

 

 

 

 

Ancillary Procedures

Appendectomy has been routinely performed by some physicians at the time of postpartum tubal sterilization provided there are no medical or surgical contraindications. To add removal of the appendix to the procedure usually requires a larger incision, extra time, and an increase in blood loss. However, at least one study has indicated that there is no difference in postoperative morbidity.25

Removal of ovarian and paratubal cysts, lysis of adhesions, and resection of endometrial implants and small leiomyomas have also been done in conjunction with the tubal procedure. Again, the limitations of anesthesia and exposure might recommend against the additional intervention, but the surgeon must judge the possible benefits against any additional risks. Each patient must be evaluated on an individual basis.

 

Complications

Tubal sterilization procedures are usually not associated with significant risk or morbidity. Data from 1979–1980 indicate that the risk of death from tubal sterilization is 1–2 per 100,000 procedures. The risk of major morbidity from tubal sterilization after cesarean or vaginal delivery is most likely related to complications of the pregnancy or delivery.26  Bleeding is the most common postoperative problem; it usually occurs as a result of inadequate ligature of the tube or failure to adequately ligate bleeding points in the mesosalpinx or broad ligament. The increased blood supply to these areas with varicosities in pregnancy lends itself to the possibility of hemorrhage and hematoma if meticulous hemostasis is not achieved.

The usual sequelae of intraabdominal surgery (e.g. paralytic ileus, abdominal distention, adhesions, intestinal obstruction) are associated with tubal sterilization procedures. Incisional infections and hematomas are less frequent but occasionally occur, especially in obese patients or in those with a chronic systemic illness.

Injury to the bladder is uncommon but may occur if the abdominal incision is too low or the bladder is distended. As mentioned previously, catheterization to ensure that the bladder is empty should be done immediately before all sterilization procedures.

Anesthesia problems are also uncommon, but inadequate anesthesia may occur, especially with regional techniques used for delivery. Supplementation with local or inhalation techniques may be necessary to complete the tubal procedure in the immediate postpartum period. The use of continuous conduction anesthesia may allow for more prolonged and consistent levels when sterilization is combined with delivery.

Precautions when using general anesthesia from the immediate postpartum period to several days after delivery are essential to minimize the possibility of aspiration and its sequelae.10, 27 Residual gastrointestinal changes due to pregnancy make preoperative preparation especially important as described in the sub-section above entitled Anesthesia Considerations.

The Pomeroy method and its modifications have the fewest overall operative complications.  The introduction of the Filshie clip for postpartum sterilizations also has great promise to be a method with high efficacy and a low incidence of complications, though a large randomized controlled trial has not been completed that would demonstrate its superiority over the Pomeroy method.

 

Side-Effects

The short-term puerperal difficulties stem mainly from discomfort at the incision site and at the points where the tubes have actually been ligated or divided. It is unusual for any significant abdominal discomfort to persist beyond 2 weeks.

There are usually no long-term alterations in a patient's menstrual or sexual functions.  After collection of data from the U.S. Collaborative Review of Sterilization (CREST Study) and a large NIH-funded study there appears to be no clinical or laboratory evidence to support previously held beliefs that tubal sterilization procedures cause menstrual abnormalities.26  The ACOG practice bulletin on sterilization concluded that "the effects of tubal sterilization on menstrual pattern disturbance appear to be negligible.7

A number of studies on patient regret following tubal sterilization emphasize the need for time for adequate, early, and repeated predelivery counseling.4, 18, 19  See the discussion of preoperative considerations from earlier in this chapter as well as the chapter on Surgical Procedures for Tubal Sterilization. The CREST Study followed patients for 14 years and found an overall probability of expressing regret was 12.7%, but women age 30 or younger had a 20.3% rate of regret versus only 5.9% amongst women who were older than 30 at the time of the tubal sterilization.28  Youthfulness (<30 years at sterilization), poststerilization family events, and discovery that the procedure is not protective against sexually transmitted diseases are the most common causes of later regret.

Effectiveness

With various tubal methods, the overall failure rate is on the order of 0.5% in the first year when the procedures are performed properly.29 Among the procedures discussed, the Irving and Uchida methods historically were associated with the fewest subsequent pregnancies, and the Madlener and Kroener methods are associated with the highest number. The most frequently used postpartum partial salpingectomy  method used today is the Pomeroy procedure or one of its modifications.  This is likely due to the fact that it is not only the safest of the methods mentioned but also has a very acceptable level of effectiveness.  The effectiveness of all permanent sterilization methods depends on the age of the women at the time of tubal sterilization.  The CREST study followed the experience of 10,685 women from 8 to 14 years after various sterilization techniques were performed and identified 143 sterilization failures.28  An age-stratified analysis of this cohort revealed that the cumulative probability of pregnancy was low for women aged 34–44 years old at the time of sterilization, but as high as 5% for women aged 18–27 years old.  Figure 6  demonstrates how the risk of pregnancy accumulates over time after all tubal occlusion methods.26

 

Fig. 6. Life-table cumulative probability of pregnancy among women who had tubal sterilization by method (cumullative probability per 1000 procedures). Reprinted from Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussel J. The risk of pregnancy after tubal sterilization: findings from US Collaborative Review of Sterilization. Am J Obstet Gynecol 1996;174:1161–8. Copyright 1996, with permission from Elsevier. 

 

The three most common causes of failure are luteal phase pregnancy if the procedure is delayed beyond 30 days from delivery; occlusion of the wrong structure, most often the round ligament; and most frequently, recanalization of the severed ends of the tube. Although there is an increased incidence of ectopic pregnancy in failures of tubal sterilization, no single technique seems to predispose to this condition30 (see Table 1.31) The highest proportion of women who had a sterilization failure resulting in ectopic pregnancy occcurred among women who had bipolar coagulation (65%) versus postpartum partial salpingectomy (20%).26, 31  

Table 1. Life-table cumulative probability of ectopic pregnancy among women who had undergone tubal sterilization, according to time since sterilization. US Collaborative Review of Sterilization

Method

 Years since sterilization 
1510
Bipolar coagulation0.5 (0.0–1.3)10.1 (5.4–14.7)17.1 (9.8–24.4)
Unipolar coagulation0.00.01.8 (0.0–5.2)
Silicone rubber band application0.6 (0.0–1.5)2.5 (0.6–4.4)7.3 (1.6–12.9)
Spring clip application1.3 (0.0–3.1)3.6 (0.4–6.7)8.5 (1.0–16.0)
Interval partial salpingectomy4.9 (0.0–11.6)7.5 (0.0–15.9)7.5 (0.0–15.9)
Postpartum partial salpingectomy0.01.5 (0.0–3.6)1.5 (0.0–3.6)
All methods0.7 (0.2–1.2)4.0 (2.6–5.3)7.3 (5.0–9.6)
Data are n/1000 procedures (95% confidence interval) Adapted from Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. The risk of ectopic pregnancy after tubal sterilization. US Collaborative Review of Sterilization Working Group. N Engl J Med 1997;336:762–7. Copyright 1997 Massachusetts Medical Society. All Rights Reserved

Noncontraceptive Benefits

Epidemiologic studies have shown a reduced risk of ovarian cancer after tubal sterilization. 7  The underlying mechanism of reducing ovarian cancer risk has yet to be determined, but population based observational studies note this association.  Also, though tubal sterilization does not provide protection from sexually-transmitted infections, it does appear to decrease the risk of hospitilzation due to pelvic inflammatory disease.  This finding is also based on epidemiologic observations, though one theory is that tubal occlusion prevents ascending pelvic infection. 7

 

HYSTERECTOMY

Cesarean hysterectomy has been used for sterilization in the presence of preexisting uterine or adnexal pathology.  However, the primary indications for cesarean hysterectomy or immediate post-vaginal delivery hysterectomy are generally due to obstetric and surgical complications at the time of delivery. Hemorrhage, hematomas, uterine injury, and serious infection are among the indications for hysterectomy after cesarean or within the first few days postpartum.

The use of these procedures for sterilization alone without other gynecologic indications has been tempered at most institutions by findings of increased blood loss and postoperative morbidity.32 However, in some studies, no increase in morbidity was found when cesarean hysterectomy and tubal ligations at cesarean section were compared.33, 34 Some physicians even think that cesarean hysterectomy may be desirable in high-parity women from lower socioeconomic groups because they may have an increased incidence of uterine and cervical disease later in life.

If sterilization is planned and major uterine disease is anticipated, the option for cesarean hysterectomy certainly should be discussed before the delivery.  However, given the extremely low failure rates of most postpartum tubal sterilization procedures combined with low surgical risk versus the near zero chance of pregnancy after hysterectomy with potentially greater surgical risk, postpartum or cesarean hysterectomy has not been a favored method of sterilization. 

Effectiveness

Hysterectomy is the most effective means of preventing pregnancy without depleting ovarian function. Rare failures in which pregnancy occurs in a prolapsed fallopian tube or from sperm passing through a fistulous tract in the vaginal vault have been recognized. However, morbidity and recovery factors rule against hysterectomy as a separate procedure following vaginal delivery unless significant complications or gynecologic pathology indicate removal of the uterus.

 

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Kohaut BA, Musselman BL, Sanchez-Ramos L et al: Randomized trial to compare perioperative outcomes of Filshie clip vs. Pomeroy technique for postpartum and intraoperative cesarean tubal sterilization: a pilot study. Contraception. 2004;69(4):267-70

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