Minilaparotomy can be performed at almost anyfacility that has surgical capacity, from a separate out-patient facility to a hospital-based facility. Sites need totake appropriate measures to ensure delivery of qualityand efficient services, with attention to clients’ comfortand satisfaction.
A facility needs good lighting, electricity, a supply ofclean water, and the capacity to handle or quickly referemergencies for the provision of high-quality sterilizationservices. In rural and remote locations, it is possible toperform minilaparotomy without a permanent source ofelectricity or reliable sources of running water.
• Light: Although the preoperative exam may be per-formed in natural light, a directed source ofadjustable light is needed for the surgery itself.Aback-up battery-operated light should be available atall times in case of power failure.
• Electricity: A reliable source of electricity is preferableto provide light for the procedure and for instrumentprocessing. If the central source of electricity is notreliable, a functional generator should be available.
• Water: The facility should have a reliable source ofclean running water. It is preferable to have clean tapwater. If piped water is not reliable, sites may usealternative clean water supplies if necessary (e.g.,cisterns) (WHO, 1992).Alternatively, water can bestored in containers, as long as the storage containersprovide a clean, free-flowing source of water.*
• Emergency capacity: The facility must always have onhand all equipment, supplies, and drugs needed tostabilize a client who experiences a complication(Appendix F).The facility should also have proceduresfor ensuring referral to higher-level facilities for furthercare, if needed.This includes ensuring the availabilityof prompt transport to such facilities if emergenciesarise.
3
Facilities
EngenderHealth 11
* A bucket with an attached tap is available in many countries.
• An examination room for preoperative and follow-upexaminations, including changing facilities for clients
• A surgical area isolated from the outside and fromclinic traffic
• A space for cleaning, preparing, and sterilizingsurgical instruments and linen
• Spaces for storing records, supplies, and equipment
• Arrangements for laboratory tests
• Toilet and washing facilities for clients and staff(preferably separate)
• A laundry or laundry arrangements
The overall surgical area consists of several smaller areaswhere the surgical activities are performed: an areawhere surgical personnel can change clothes, an area forsurgical scrub, an area for storing prepared instruments,and the operating theater.The operating theater should
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TABLE 3. Instruments for minilaparotomy for female sterilization
EngenderHealth Facilities, Equipment, Instruments, and Supplies 13
be enclosed, be clean, and possess a good ventilationsystem. It should also be isolated from open transitareas, with access limited to those involved in surgicalactivities.The operating theater should not be used as astorage room; only the items regularly used for surgicalprocedures should be kept there. It should also be asclose as possible to the client recovery room.
The equipment, instruments, and supplies needed forperforming minilaparotomy are generally available inmost facilities where surgical services are offered.Appendix A lists the basic equipment, instruments, andsupplies needed, and Table 3 lists the surgical instru-ments needed for minilaparotomy. Figure 2 shows thetwo specialized instruments—the uterine elevator andthe tubal hook—that are needed for the minilaparotomyprocedure. Figure 3 (page 14) shows the instrumentsneeded for inserting the uterine elevator (used with thesuprapubic procedure). Finally, Figure 4 (page 14) showsthe instrument tray organized for the procedure.
Equipment,Instruments, and
Supplies
FIGURE 2. Instruments specific to minilaparotomyprocedures
Uterine elevator
Tubal hook
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14 Minilaparotomy for Female Sterilization EngenderHealth
FIGURE 3. Instruments used for inserting the uterineelevator
FIGURE 4. Instrument tray used for performingminilaparotomy
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Counseling is the process by which a health careprovider uses empathetic, two-way communication tohelp clients explore their reproductive health needs, sothey can make a voluntary, informed, and well-considered decision that is compatible with thoseneeds. For a client making the decision about femalesterilization, counseling should be performed well inadvance of the procedure, since sterilization is asurgical procedure that is meant to be permanent.
Informed decision making is a part of the coun-seling process through which a client makes a well-considered, voluntary decision about contraceptive use.This decision should be reached based on options,information, and an understanding of the risks ofpregnancy and sexually transmitted infections (STIs)and the levels of protection provided by differentcontraceptive methods, including the understanding ofrelevant medical facts and the potential risks involvedwhile using contraceptives—and, more importantly inthe case of female sterilization, about the procedureand its effects and about the risks and benefits asso-ciated with the surgery.This information should betailored to individual clients, filling gaps in theirknowledge, correcting any misinformation, and ad-dressing their questions and concerns. Clients shouldbe able to make a real choice among contraceptiveoptions that are offered and explained.They shouldalso receive information about female sterilization’slack of protection against STIs, including HIV, and theyshould be aware that dual protection may be advisablein some situations.
Informed consent, on the other hand, is the client’swritten acceptance, agreement, or permission, basedon his or her own free will, to undergo a medical orsurgical procedure after having made an informeddecision. For female sterilization, the client givesinformed consent after being counseled, by signing(or by putting her thumb impression on) a consent
form before the procedure is performed. (A sampleinformed consent form is provided in Appendix B.)
Postpartum clients should have received informationand made their decision regarding female sterilizationduring their pregnancy.As part of clients’ antenatal care(if this was received), providers should have discussedtheir family planning intentions, and decisions shouldhave been made before the onset of labor. This ensuresthat the decision was thought out and was not madeduring a stressful situation. If a postpartum or post-abortion client who had not received counseling duringher pregnancy requests female sterilization, efforts mustbe made to assess her decision and ensure that she ismaking a well-informed and free decision, but theprocedure should not be denied without consideration.
The preoperative assessment should be conductedbefore surgery is scheduled, to screen for conditionsthat warrant caution, delay, or special consideration, asdescribed in the medical screening guidelines forfemale sterilization developed by the World HealthOrganization (WHO, 2002) (see Appendix C). Generally,an interval client is assessed after her counselingsession.A pregnant client who is considering femalesterilization as her contraceptive option should beassessed before the surgical procedure to ensure thatshe is a fit for surgery.
Who is responsible for the preoperative assessment? Anyhealth care provider trained in taking a complete med-ical history and in performing a complete physicalexam, including a pelvic exam, can perform the preop-erative assessment.This person should know the WHOMedical Eligibility Criteria for Female Sterilization(WHO, 2002) and should be qualified to recognize andappropriately identify conditions that might lead tosurgical complications.
Components of the preoperative assessment. In the pre-operative assessment, the provider takes a completemedical history and conducts a physical exam; in somecases, the preoperative assessment may also includeperforming laboratory tests.A suitable preoperativeassessment will diminish the incidence of unwanted
PreoperativeAssessment
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events in the perioperative period, as well asunexpected or unscheduled hospitalizations inambulatory surgery programs (White, 1994).
The medical history that is taken must be complete,whether or not questions are specifically related to thesurgical procedure.The medical history includes ahistory of past medical conditions (related to eachorgan system), a reproductive health history (e.g.,number of pregnancies, number of living children andtheir age, last pregnancy outcome and last normalmenstrual period, contraceptive history, and history ofSTIs or HIV), and a history of any previous surgeries,anesthesia, allergies, and medications. Clients should beasked about any current illness or any symptoms thatcould add risk to the procedure or that could warranta postponement.
The physical exam should include taking and docu-menting vital signs and conducting a cardiopulmonary,abdominal, and gynecological exam. In postpartumclients, an abdominal exam is important for assessing thesize and relative location of the uterine fundus. Forclients who will be having an interval or postabortionminilaparotomy, the physical exam should include abimanual pelvic exam to determine the position, flexion,mobility, size, shape, and condition of the uterus (Fig. 5,page 18, and Fig. 6, page 19).
HINT: The mobility of a retroverted or retro-flexed uterus should be carefully assessed. Al-though the surgeon may be able to gain accessto the tubes by bending a retroverted or retro-flexed uterus that is mobile, a uterus that isretroverted or retroflexed and fixed will notbend easily and may require a different surgi-cal approach—e.g., a larger incision or moreanesthesia (AVSC International, 1995).
The possibility of pregnancy must also be ruled out,but there is no need to perform a pregnancy test;instead, the examining provider may use the ProviderChecklist for Reproductive Health Services: How toBe Reasonably Sure a Client Is Not Pregnant(Appendix D).
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Additionally, for postpartum clients, the presence of anycomplicating conditions related to the delivery (e.g., po-tential infection, excessive blood loss during delivery orimmediately postpartum, and complications associatedwith pregnancy-induced high blood pressure) should beassessed.The well-being of the baby should also beassured.A bimanual examination need not be performed.
For postabortion clients, the provider must be sure thatthere is no infection, uterine perforation, or significantblood loss. Uterine size should also be assessed, as thiswill influence the surgical approach selected.
Diagnostic laboratory tests such as hematocrit orhemoglobin are necessary only when warranted by theclient’s history or the results of the physical exam. Inthe event that either general anesthesia or regionalanesthesia is being considered, laboratory tests shouldbe performed according to respective national orinternational guidelines.
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FIGURE 5. Bimanual pelvic examination of anormal anteverted uterus
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Medical EligibilityCriteria for Female
Sterilization
EngenderHealth Counseling, Preoperative Assessment, and Scheduling 19
There is no medical reason that would absolutelyrestrict a woman’s eligibility for female sterilization.Some conditions and circumstances, which should beidentified during the preoperative assessment, mayindicate the need to take certain additional precautions,however.Appendix C provides screening guidelines forfemale sterilization. Medical conditions are classified asA (Accept), C (Caution), D (Delay), and S (Special).
The majority of clients are classified under Accept, andtheir procedure can be performed in most clinicalsettings. Clients identified with conditions requiringCaution can be scheduled in the normal setting butwith extra precautions, as required. Clients withconditions requiring Delay should be scheduled whenthe condition is further evaluated or corrected (seeTable 4, page 20, for examples). Clients identified with
FIGURE 6. Bimanual pelvic examination of aretroverted or a retroflexed uterus
Retroverteduterus
Retroflexeduterus
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20 Minilaparotomy for Female Sterilization EngenderHealth
TABLE 4. Conditions warranting either delay of surgery or observation of specialconsiderations before surgery is performed
Delay Special Consideration
Pregnancy
Postpartum
• Seven up to 28 days
• Severe preeclampsia or eclampsia
• Prolonged rupture of membranes (24 hours or more)
• Puerperal sepsis, or intrapartum or puerperal fever
• Severe antenatal or postpartum hemorrhage
• Severe trauma to the genital tract
Postabortion
• Postabortion sepsis or fever
• Severe trauma to the genital tract
• Acute hematometra
Deep venous thrombosis or pulmonary embolism
• Current deep venous thrombosis or pulmonary embolism
• Major surgery with prolonged immobilization
Current and history of ischemic heart disease
Unexplained vaginal bleeding
Malignant gestational trophoblastic disease
Cervical, endometrial, or ovarian cancer
Pelvic inflammatory disease (current or within the last three months)
Current sexually transmitted infection (including purulent cervicitis)
Current gall bladder disease
Active viral hepatitis
Iron deficiency anemia (Hb �7g/dL)
Abdominal skin infection
Acute bronchitis or pneumonia
Gastroenteritis
Sterilization at the same time as abdominal surgery
• As an emergency (without previous counseling)
• With an infectious condition
Adapted from: WHO, 2002.
Postpartum uterine rupture or perforation
Postabortion uterine perforation
Multiple risk factors for arterialcardiovascular disease
Hypertension
• Systolic blood pressure �160 mm Hg ordiastolic blood pressure �100 mm Hg
• Vascular disease
Complicated valvular heart disease
Endometriosis
AIDS
Tuberculosis or known pelvic infection
Diabetes with nephropathy, retinopathy, orneuropathy
Hyperthyroidism
Decompensated severe cirrhosis
Coagulation disorders
Chronic respiratory diseases
Hernia of the abdominal wall or umbilicus
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conditions requiring Special consideration should bescheduled in a setting that ensures appropriate hand-ling of clients with higher risk for surgery (see Table4).When assessing a client for female sterilization, theprovider should also weigh the risks inherent in afuture pregnancy against the risk for any potentialconditions that would require special considerationfor the surgical procedure.
After being counseled and receiving preoperativeassessment, clients who will undergo female sterilizationshould be scheduled for surgery. Scheduling includessetting a time, providing alternative contraception ifneeded, and providing preoperative and postoperativeinstructions.These instructions should be given bothverbally and in writing. (Most of the time, they arepresented as a client brochure [see Appendix E].)
NOTE: For postpartum and postabortion clients, thetime for surgery should be set according to the recom-mendations shown in Table 1—usually within 48 hoursof delivery or within the first six hours after uterineevacuation, respectively.
Setting a time. For the interval client, female sterilizationshould be performed within the first two weeks of theclient’s menstrual cycle. If the provider can be sure thatthe woman is not pregnant (e.g., she is correctly using areliable method of contraception or she is not sexuallyactive), then the surgery can be scheduled for any time.
Providing temporary contraception. If a client is notwithin the first two weeks of her last menstrual cycle,if pregnancy cannot be ruled out, if any conditionrequires a delay in performing the surgery, and if she isnot already using a reliable method of contraception,the client should be offered a reliable method ofcontraception so she is protected from pregnancyuntil her surgery can be performed.
Providing preoperative information and instructions.Preoperative information and instructions should begiven both verbally and in writing.A responsible adultshould accompany the client to the facility on the dayof the surgery. (Sample written preoperative instruc-tions are provided in Appendix E.)
Scheduling
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Preoperative information and instructions are impor-tant.To inform and reassure the client, these shouldbe given in advance, letting her know what to expectduring the procedure.This is key to the success oflocal anesthesia and decreases the need for sedationand analgesia. Using simple terms, the counselorgenerally provides the following information duringcounseling:
• The steps of the operation
• The anesthesia regimen to be used, an explanationthat some discomfort might occur, and encourage-ment for the client to ask questions
• The important fact that clients should not eat anysolid food for at least six hours before surgery, butmay take clear fluids up to two hours before surgery(Barash et al., 2001)
• The need for interval clients to bathe, clean thegenital area and operative site, and remove jewelry,make-up, and nail polish on the day of the surgery
• The importance of having a responsible adult to takethe client home from the facility after the procedure
In addition, information about what to expect after thesurgery should be provided at this time, and it shouldinclude the following:
• Needed rest, wound care, and when to restartnormal activities (including intercourse)
• Warning signs to be aware of, what to do in eachcase, and where to go in the event those compli-cations arise
• When and where to go for the follow-up visit
Providing postoperative instructions. After surgery, theinformation already provided regarding postoperativecare should be reiterated and reviewed.These instruc-tions are especially important in helping womenrecognize warning signs and seek timely care. Clientsshould receive written instructions just before they leavethe facility, with special attention to the following advice:
• Rest for the remainder of the day. Resume normalactivities after two or three days.
• Avoid intercourse until comfortable.
• For relief of pain or discomfort, take simpleanalgesics at intervals of four to six hours. (Note:Name and dose should be specified.)
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• Keep the wound clean and dry.
• The stitches will dissolve by themselves and do nothave to be removed. (Note:This instruction must bemodified if nonabsorbable suture, such as silk, isused.)
• Remember routine follow-up dates and times.
• Keep in mind where to go for urgent care in casewarning signs develop, such as fever, persistent andincreasing pain in the abdomen, bleeding from theincision site, or suspected pregnancy.
(Sample written postoperative instructions areprovided in Appendix E.)
EngenderHealth Counseling, Preoperative Assessment, and Scheduling 23
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