Postpartum Tubal Sterilization EPUB version of this bookEPUB version of this book

AMERICAN SOCIETY OF ANESTHESIOLOGISTS GUIDELINES

The American Society of Anesthesiologists (ASA) has published “Practice Guidelines for Obstetric Anesthesia,” which includes a discussion of postpartum tubal ligation. The Task Force recommendations can be summarized as follows:

1.
Before a postpartum tubal ligation, the patient should have no oral intake of solid foods within 6 to 8 hours of the surgery, depending on the type of food ingested (e.g., fat content).
2.
Consider aspiration prophylaxis.
3.
Both the timing of the procedure and the decision to use a specific anesthetic technique (i.e., neuraxial versus general) should be individualized, based on anesthetic and obstetric risk factors (e.g., blood loss at delivery) and patient preferences.
4.
Consider selecting neuraxial techniques in preference to general anesthesia for most postpartum tubal ligations.
5.
Be aware that gastric emptying will be delayed in patients who have received opioids during labor.
6.
Be aware that an epidural catheter placed for labor may be more likely to fail with longer postdelivery time intervals.
7.
If a postpartum tubal ligation is to be performed before the patient is discharged from the hospital, do not attempt the procedure at a time when it might compromise other aspects of patient care on the labor and delivery unit.

SURGICAL CONSIDERATIONS

Tubal sterilization can be performed satisfactorily at any time, but the early postpartum period has several advantages for women who have had an uncomplicated vaginal delivery. The patient avoids the cost and inconvenience of a second hospital visit. The uterine fundus remains near the umbilicus for several days postpartum, which allows easy access to the fallopian tubes via a mini-laparotomy. Mini-laparotomy and laparoscopy have similar rates of serious complications (e.g., bowel laceration, vascular injury), although postpartum tubal ligation is associated with lower failure rates than interval laparoscopic tubal ligation. Finally, costs may be lower with postpartum mini-laparotomy.

There are at least two potential disadvantages to immediate postpartum sterilization. First, parous women are at increased risk for uterine atony and postpartum hemorrhage. This risk decreases substantially 12 hours after delivery. Second, immediate surgery results in sterilization before the assessment of the newborn is complete. Postpartum tubal ligation is not wise if the patient is ambivalent regarding permanent sterilization. The probability of regret diminishes steadily with increased interval between delivery and sterilization. The key indicators for future regret are younger age, less than 30 years; having less access to information about alternative contraceptive methods; and having made the decision under pressure from a partner or because of medical indications. Women should be counseled about failure, regret, and alternatives such as long-acting, reversible contraceptives (e.g., intrauterine device [IUD], subdermal implants), but younger age and lower parity should not be a barrier to sterilization.

Several techniques are used for postpartum tubal sterilization ( Fig. 25.1 ). Postpartum sterilization has a failure rate that is lower than most interval procedures, and the failure rate is lowest (approximately 0.75%) if some form of tubal resection occurs. With the Irving procedure, the obstetrician buries the cut ends of the tubes in the myometrium and mesosalpinx. This technique is least likely to fail, but it requires more extensive exposure and increases the risk for hemorrhage. The Pomeroy procedure is simplest. The surgeon ligates a loop of oviduct and excises the loop above the suture. With the Parkland procedure, the obstetrician ligates the tube proximally and distally and then excises the mid-segment. The last two methods are most commonly performed during postpartum tubal ligations. Regardless of the technique, the obstetrician should document that fimbriae are present to preclude ligation of another structure, such as the round ligament. The excised portions are typically sent to a pathologist for verification.

An illustration compares five labeled tubal sterilization techniques, including Irving, Pomeroy, Parkland, Madlener, and Kroener fimbriectomy. — Fig. 25.1

Recently, surgical technique has changed, and instead of performing a tubal ligation alone for sterilization, some surgeons are recommending bilateral salpingectomy. Ovarian cancer often arises from the fallopian tubes, and bilateral salpingectomy reduces the incidence of ovarian cancer by 64%, an estimated 422 fewer ovarian cancer diagnoses and 252 fewer deaths over 10 years. Postpartum salpingectomy is a cost-effective procedure without additional complications compared with tubal ligation.

NONMEDICAL ISSUES

Nonmedical issues affect decisions regarding the timing of tubal sterilization. The obstetrician must obtain and document informed consent for surgery. Tubal ligation should be considered an irreversible procedure. Therefore, most obstetricians require a discussion with the patient before labor and delivery. Physicians should be aware of state laws or insurance regulations that may require a specific interval between obtaining consent and performance of sterilization procedures. Regulations may not allow the woman to give consent while in labor or immediately after delivery. For example, the Colorado Medicaid reimbursement program includes the following requirements for sterilization :

•
The patient must be at least 21 years of age and mentally competent when consent is obtained.
•
Informed consent may not be obtained while the patient is in labor or during childbirth.
•
Consent may not be obtained while the patient is undergoing an abortion or under the influence of alcohol or other substances.
•
A total of 30 days must pass between the date the consent is signed and the date the procedure is performed. (Exceptions to the 30-day waiting period can be made for preterm delivery or emergency abdominal surgery.)
•
Consent is valid for only 180 days.

An ethical analysis of the Medicaid sterilization consent requirements suggests they merit revision because they present a barrier to desired sterilization for some women. Women with private insurance are not required to follow these requirements, creating a two-tiered system based on the ability to pay. Factors that may decrease the likelihood of a patient obtaining desired postpartum sterilization include patient-related factors, obstetrician-related factors, lack of available operating rooms and anesthesia coverage, federal consent requirements as discussed above, and receiving care in some religiously affiliated hospitals. The requirements create disparities and inequity for minority women, women with less education, and those who are economically disadvantaged by resulting in a disproportionate incidence of unplanned pregnancy.

In some cases, the obstetrician may schedule a patient for a postpartum tubal sterilization because of a fear that the patient will not return for interval tubal sterilization 6 weeks after delivery. Concerns regarding patient compliance should not prompt the performance of postpartum tubal sterilization in patients with significant medical or obstetric complications. However, women who request postpartum tubal sterilization but do not receive it are more likely to become pregnant within 1 year of delivery (46.7%) than are women who did not request the procedure (22.3%).

The American College of Obstetricians and Gynecologists (ACOG) has stated that given the consequences of a missed procedure and the limited time frame in which it may be performed, institutions should consider designating postpartum sterilizations as nonelective procedures, which indicates its high priority to staff and schedulers. They also stated that obstetrician-gynecologists should identify and eliminate barriers that restrict access to postpartum sterilization. The ACOG concluded that obstetrician-gynecologists should be champions or patient advocates for postpartum sterilization in their respective hospitals and help to coordinate administration and healthcare staff in streamlining access to the procedure. If individual physicians or institutions will not provide sterilization because of personal religious beliefs or institutional policy, patients must be informed as early as possible and transfer of care for the remainder of pregnancy should be offered. Increasing access and availability of postpartum sterilization may not only directly improve outcomes for women desiring the procedure, but may decrease overall costs to the healthcare system.

PREOPERATIVE EVALUATION

The patient scheduled for postpartum tubal sterilization requires a thorough preoperative evaluation, and a reevaluation should be performed even if the patient is known to the anesthesia provider because of the provision of labor analgesia. A cursory evaluation should not be performed simply because the patient is young and healthy. Patients with preeclampsia may safely receive neuraxial or general anesthesia for postpartum tubal sterilization, provided that there is no evidence of pulmonary edema, oliguria, or thrombocytopenia.

Physicians and nurses often underestimate blood loss during delivery and some form of quantitative measurement of blood loss should be used. Excessive blood loss from uterine atony is not uncommon in parous women. Orthostatic changes in blood pressure and heart rate should be excluded, especially if an immediate postpartum procedure is to be performed. At the University of Colorado, for surgery performed the day after delivery, the patient’s hematocrit is determined several hours after delivery (to allow for equilibration) and compared with the antepartum measurement. A hematocrit is not obtained before an immediate postpartum tubal sterilization (performed less than 8 hours after delivery), provided that the antepartum hematocrit was acceptable, there are no orthostatic vital sign changes, and there was no evidence of excessive blood loss during delivery.

No absolute value of hematocrit requires a delay of surgery, but physical signs of hypovolemia—such as hemodynamic instability or laboratory evidence of excessive blood loss—should prompt postponement of the procedure until 6 to 8 weeks postpartum. Fever may signal the presence of endometritis or urinary tract infection and may also require postponement of surgery until a later date. Finally, the condition of the neonate should be confirmed before surgery to exclude any unexpected problems.

Mothers may be concerned that medications administered during surgery might affect their ability to breastfeed or that these medications might harm the newborn. Any drug present in the mother’s blood will be present in breast milk, with the concentration dependent on factors such as protein binding, lipid solubility, and degree of ionization. Typically, the amount of drug present in breast milk is small and clinically insignificant. Opioids, benzodiazepines, and propofol administered during anesthesia are excreted in insignificant amounts. (See Chapter 16 for a detailed discussion of interactions between drugs and breastfeeding.)

RISK FOR ASPIRATION

Historically, anesthesiologists have considered maternal aspiration the major risk associated with anesthesia for postpartum tubal sterilization, although the evidence for this is scant and conflicting. A review of anesthesia-related maternal mortality found no maternal deaths associated with aspiration during postpartum tubal ligation, despite tracking deaths for an entire year after delivery. A review of serious complications related to obstetric anesthesia sponsored by the Society for Obstetric Anesthesia and Perinatology also did not identify any cases of aspiration during postpartum tubal ligation. However, several factors may place the pregnant woman at increased risk for aspiration. Some but not all risk factors for aspiration are resolved at delivery. For example, the placenta is the primary site of progesterone production, and progesterone concentrations fall rapidly after delivery of the placenta ( Fig. 25.2 ). Typically, progesterone concentrations decline within 2 hours of delivery; and by 24 hours postpartum, progesterone concentrations are similar to those found during the luteal phase of the menstrual cycle.

A line graph shows maximum, average, and minimum progesterone levels across stages from 34 weeks to 24 hours postpartum. — Fig. 25.2

Important questions to address during the preanesthetic evaluation are: (1) What is the duration of the fast for solid foods? (2) Were parenteral opioids administered during labor? (3) If epidural labor analgesia was used, was the patient satisfied with their pain control?

Gastric Emptying, Reflux, and Aspiration Risk

Several studies have assessed gastric emptying in pregnant and postpartum women. Vial et al. used ultrasonographic assessment of gastric contents in laboring women after epidural analgesia was initiated and again after delivery in the immediate postpartum period. Using an antral cross-sectional area of less than or equal to 381 mm ² to define an empty stomach, 65% of women had stomach contents after epidural catheter placement and 48% after delivery. No risk factors, such as pain, anxiety, diabetes, or smoking, were associated with the occurrence of a full stomach postdelivery. Bouvet et al. compared four groups of women: nonpregnant, term pregnant, parturients with no labor analgesia, and parturients with epidural labor analgesia to determine the fraction of gastric emptying at 90 minutes following a light meal using serial gastric ultrasound. They found the median fraction of gastric emptying was 52% in nonpregnant women, 45% in term pregnant women, 7% in women laboring with no analgesia, and 31% in laboring women with epidural analgesia ( P <.0001) ( Fig. 25.3 ). They concluded that gastric emptying is delayed in laboring compared with nonpregnant women and compared with pregnant women at term not in labor, but epidural labor analgesia facilitates emptying during labor compared with no epidural analgesia.

A bar graph compares gastric emptying fraction and half time across four groups, including nonpregnant, pregnant, and laboring women. — Fig. 25.3

During the preoperative assessment of any woman scheduled for postpartum tubal sterilization, the anesthesia provider should determine when the patient last consumed solid food and whether opioids were administered by any route. Systemic absorption of an opioid occurs after epidural administration. However, published studies have provided conflicting results regarding the effect of epidural opioid administration on gastric emptying. Taking these findings into account, the ASA Committee on Obstetric Anesthesia made the following statements and recommendations : (1) gastric emptying in labor is delayed; it is further delayed by systemic opioids and high-dose neuraxial opioids; (2) lower esophageal sphincter tone is reduced and 50% of women have reflux symptoms by the third trimester; (3) no benefits have been shown for solid food compared with clear liquid intake during labor, although maternal satisfaction may be adversely affected; (4) both the ASA and ACOG guidelines state that consumption of solid food in active labor should be avoided; (5) because strict NPO ( nil per os ; nothing by mouth) policies can cause patient distress, clear liquids should be encouraged during uncomplicated labor; and (6) neuraxial analgesia should not be denied, regardless of fasting status or stomach contents. In contrast to these recommendations, other experts feel restrictions on oral intake during labor should be relaxed given the minimal risk of aspiration in the setting of modern obstetric practice.

In summary, the preponderance of evidence suggests that (1) administration of an opioid during labor increases the likelihood of delayed gastric emptying during the early postpartum period, (2) gastric emptying of solid food is delayed during labor and in the immediate postpartum period in all parturients, and (3) gastric emptying of clear liquids is probably not delayed unless intrapartum parenteral opioids were administered.

Summary of Aspiration Risk and Prevention

No data indicate that the postpartum patient’s safety is enhanced by delaying surgery or is compromised by proceeding with surgery immediately after delivery. The lack of data has led to confusion and inconsistency in the development of policies for the performance of postpartum tubal sterilization. No particular waiting interval guarantees that the postpartum patient is free of risk for aspiration. It is probably prudent to use some form of aspiration prophylaxis in all patients undergoing postpartum tubal sterilization. However, significant aspiration pneumonitis is so rare that it will be difficult to document cost-effectiveness and decreased rates of morbidity and mortality from the use of these measures. H ₂-receptor antagonists and antacids do not reduce the possibility of regurgitation and aspiration, but they may make the consequences less severe. Metoclopramide (a prokinetic agent) may decrease the incidence of reflux by increasing lower esophageal sphincter tone and hastening gastric emptying. None of these medications can guarantee that gastric contents will not enter the lungs. Aspiration is best prevented by an experienced anesthesia provider using careful airway management or by use of a neuraxial anesthetic technique.

TIMING OF POSTPARTUM TUBAL LIGATION SURGERY

Performance of an immediate postpartum tubal sterilization (within 8 hours of delivery) may decrease both length of hospital stay and hospital costs. In this era of healthcare cost-containment, any decision to postpone surgery that requires an extra day of hospitalization must be evaluated carefully. Possible reasons to consider a delay after delivery are as follows: (1) women may remain at increased risk for gastroesophageal reflux immediately after delivery; (2) delays in gastric emptying due to the antepartum administration of opioids will resolve during this period; (3) an 8-hour delay allows the administration of aspiration prophylaxis drugs, although they might also be given during labor; (4) maximal hemodynamic stress and potential instability occur immediately postpartum when central blood volume suddenly increases because of contraction of the evacuated uterus, relief of aortocaval compression, and loss of the low-resistance placental circuit (although unlikely to affect healthy parturients, the patient with cardiovascular disease is at greatest risk for hemodynamic decompensation immediately postpartum); (5) if there are concerns about excessive blood loss at delivery, an 8-hour delay allows the physician to assess serial hemodynamic measurements (including the presence or absence of orthostatic changes), obtain an equilibrated postpartum hematocrit, and, if necessary, restore intravascular volume; (6) delay allows a more thorough evaluation of the infant; and (7) delay allows the woman more time to assess her decision and minimize the possibility of regret. However, it is important to remember that women who request postpartum tubal sterilization but do not receive it before discharge from the hospital are twice as likely to become pregnant within 1 year of delivery than women who did not request the procedure. The ACOG has stated that given the consequences of a missed procedure, postpartum sterilization should be considered an urgent surgical procedure. Anesthesia providers should be aware of their role in advocating with obstetricians for completion of the procedure in a timely fashion.

At the University of Colorado, we follow standard NPO guidelines (i.e., no solid foods for 6 to 8 hours [depending on fat content] and no clear liquids for 2 hours) before postpartum tubal sterilization. NPO policies for postpartum tubal sterilization should not differ from those used for elective surgery in the main operating rooms. Immediate postpartum tubal sterilization may be performed in patients who have a functioning epidural catheter in place. These patients are given an H ₂-receptor antagonist and metoclopramide intravenously prior to surgery, and a clear (nonparticulate) antacid is administered just before taking the patient to the operating room. In other patients who did not want (or were unable to receive) epidural analgesia for labor, similar precautions are used. Before surgery, quantitative blood loss from delivery is reviewed and orthostatic vital signs may be assessed. Most patients without preexisting epidural analgesia receive spinal anesthesia for postpartum tubal sterilization, with sedation if requested. However, if the patient strongly prefers, general anesthesia can be provided using rapid-sequence induction of anesthesia with cricoid pressure.

ANESTHETIC MANAGEMENT

Local, general, or neuraxial anesthesia may be used successfully for postpartum tubal sterilization. Physiology remains altered in the postpartum patient and requires some modification in anesthetic technique. It seems reasonable to give all postpartum patients some form of aspiration prophylaxis. This may include a clear (nonparticulate) antacid, an H ₂-receptor antagonist, and/or metoclopramide to increase lower esophageal sphincter tone and hasten gastric emptying. Metoclopramide also may reduce emesis during and after surgery. Patients with additional risk factors for aspiration (e.g., morbid obesity, diabetes mellitus) warrant prophylaxis with all three classes of drugs. Tubal sterilization does not require administration of preoperative antibiotics.

Local Anesthesia

Local anesthesia is used widely for tubal sterilizations worldwide, although neuraxial anesthesia is most often administered for postpartum tubal sterilization in the United States. Several reports have documented the efficacy and safety of local anesthesia for postpartum or laparoscopic tubal ligation in the hospital operating room or a freestanding outpatient facility. Cruikshank et al. described the use of intraperitoneal lidocaine for postpartum tubal ligation. After intravenous (IV) administration of diazepam, lidocaine 100 mg was used to infiltrate the skin and subcutaneous tissue. The peritoneum was entered, and 400 mg of lidocaine (80 mL of 0.5% solution) was instilled into the peritoneal cavity. A Pomeroy tubal ligation was performed 5 minutes later. All patients had complete peritoneal anesthesia, and all patients stated they would have the same procedure again. None recalled any pain or discomfort 24 hours later. There were no signs of lidocaine toxicity in any patient, and the maximum lidocaine blood level obtained was 5.3 µg/mL (the toxic blood level is generally considered greater than 5 µg/mL). Surgeons rated the conditions excellent. This study was published in 1973, when anesthesiologists may or may not have been involved and before ASA monitoring standards such as pulse oximetry existed. An alternative local anesthetic might be 2-chloroprocaine, an ester local anesthetic which has less risk of systemic toxicity, thus allowing a greater intraperitoneal volume to be used.

Poindexter et al. described almost 3000 laparoscopic tubal sterilization procedures performed with local anesthesia in an ambulatory surgical facility. After IV sedation with large doses of midazolam (5 to 10 mg) and additional fentanyl (50 to 100 µg), the skin was infiltrated with 10 mL of 0.5% bupivacaine. After insertion of the trocar, the abdomen was insufflated with nitrous oxide. Each tube was sprayed with 5 mL of 0.5% bupivacaine, and a Silastic ring was applied. Patients were discharged home after approximately 1 hour in the postanesthesia care unit. The authors reported a technical failure rate of 0.14% and no unintended laparotomies or intraoperative complications. They reported that this technique reduced surgical time by 33% and cost by 68% to 85% compared with general anesthesia. The investigators presented no data regarding patient satisfaction, and they made no comment on the use of pulse oximetry or blood pressure monitors. Four percent of patients, however, required oxygen therapy for “adequate tissue perfusion.” This study was done in the 1980s before many ambulatory surgery facilities had institutional guidelines for sedation.

General Anesthesia

Much of the impetus for performing sterilization procedures under local anesthesia came from two reports in 1983 indicating that morbidity and mortality were much higher when general anesthesia was used. It is important to realize that these reports preceded the mandatory use of pulse oximetry and capnography and do not reflect modern anesthesia care. The first report involved 3500 interval (not postpartum) laparoscopic tubal sterilizations at nine university medical centers. Among all patients, the risk for intraoperative or postoperative complications was 1.75%, but the risk was five times higher with general anesthesia than with local anesthesia. (In this report, local anesthesia included local, epidural, and spinal anesthesia.) The reason(s) for the difference was unclear. In the second report, the US Centers for Disease Control and Prevention examined deaths attributed to tubal sterilization procedures from 1977 to 1981. Both immediate postpartum laparotomies and interval laparoscopic procedures were included. Of the 29 deaths, 11 followed complications of general anesthesia and were caused by hypoventilation or cardiorespiratory arrest. Aspiration was not reported as a cause of death. Of the six patients whose deaths were definitely attributed to hypoventilation, none had undergone tracheal intubation. Five of the 11 deaths attributed to general anesthesia occurred during postpartum laparotomy. Of these, only one woman had undergone tracheal intubation; all others underwent mask ventilation. The investigators concluded, “It appears that for tubal sterilization, like abortion, the greatest risk for death is that associated with the anesthesia used during the procedure.”

In the 40 years since those reports, appropriate airway management with tracheal intubation has become standard practice during general anesthesia. Adherence to ASA standards for basic anesthesia monitoring (including use of pulse oximetry and capnography to monitor oxygenation and ventilation) reduces morbidity and mortality associated with general anesthesia. At the University of Colorado, rapid-sequence induction (with cricoid pressure) is performed, and all patients undergo tracheal intubation during the administration of general anesthesia for postpartum tubal sterilization.

Volatile anesthetic agents cause uterine relaxation and could potentially increase the risk for postpartum hemorrhage if administered to women in the immediate postpartum period. Therefore, the question arises whether the anesthesia provider should use an inhalation or an IV technique to maintain general anesthesia for postpartum tubal sterilization. Marx et al. measured postpartum uterine activity and the response to oxytocin with different concentrations of halothane or enflurane ( Fig. 25.4 ). Impairment of spontaneous uterine activity occurred at 0.5 minimum alveolar concentration (MAC) of both agents, and loss of the response to oxytocin occurred near 1 MAC. Spontaneous contractions reappeared when anesthetic concentrations were reduced below these levels. Parous women are at risk for postpartum uterine atony and administration of a high concentration of a volatile halogenated agent may precipitate postpartum hemorrhage.

A two-part graph shows uterine pressure and blood halothane level over time, with labeled halothane doses and Pitocin administration. — Fig. 25.4

Two studies have determined the MAC of isoflurane during the postpartum period. Chan and Gin found a positive correlation between MAC and the length of time after delivery, with return to higher nonpregnant values achieved by 72 hours postpartum. Zhou et al. determined that the MAC of isoflurane was approximately 0.75% in the first 12 hours postpartum and 1.04% in patients who were 12 to 24 hours postpartum. No significant difference in MAC existed between the latter group and a control group of nonpregnant gynecologic patients. Together these results demonstrate that the reduced MAC observed during pregnancy persists for a variable period between 12 and 36 hours postpartum.

Propofol has advantages (e.g., rapid awakening, decreased incidence of emesis) that make it attractive as an induction agent for short sterilization procedures. When propofol was used for induction and maintenance of anesthesia for cesarean delivery, breast milk samples obtained at 4 and 8 hours postpartum had a low concentration of the drug, which suggested a negligible newborn exposure to propofol.

Alterations occur in the activity of both depolarizing and nondepolarizing muscle relaxants during the postpartum period. Evans and Wroe described the changes in plasma cholinesterase activity during pregnancy. A rapid decline in activity occurred during the first trimester. This low level of activity was maintained until delivery and was followed by an even lower level of activity during the first week postpartum. Leighton et al. studied four groups of patients: nonpregnant, nonpregnant using oral contraceptives, term pregnant, and postpartum women. Cholinesterase activity was significantly lower in both term pregnant and postpartum women, and recovery time was 25% longer in the postpartum patients than in other groups (685 seconds versus approximately 500 seconds) ( Fig. 25.5 ). Although a 3-minute prolongation of paralysis may not seem clinically significant, it could be important if airway difficulties occur. Metoclopramide prolongs neuromuscular block with succinylcholine by 135% to 228% because of its inhibition of plasma cholinesterase.

A bar graph compares twitch height recovery and cholinesterase activity across four groups of women, including postpartum and pregnant. — Fig. 25.5

Several studies have evaluated the use of the nondepolarizing muscle relaxants rocuronium, vecuronium, and cisatracurium in postpartum patients. Rocuronium’s duration of action is prolonged by approximately 25% in postpartum patients, and the duration of action of vecuronium is prolonged by more than 50%. In contrast, the duration of action for cisatracurium is significantly shorter in the postpartum period. Prolongation of neuromuscular block could be clinically significant during a short procedure. Khuenl-Brady et al. suggested that a relative decrease in hepatic blood flow and/or competition between vecuronium and steroid hormones for hepatic uptake may interfere with the hepatic clearance of vecuronium in postpartum women. Alternatively, Gin et al. concluded that the duration of action for rocuronium is not prolonged in postpartum women if lean body mass—rather than total body weight—is used to calculate dose. These researchers speculated that the prolonged duration noted earlier might be explained by relative drug overdose if the dose of rocuronium is based on the patient’s gravid body weight. Although it is unlikely a nondepolarizing muscle relaxant would be necessary for a short procedure such as postpartum tubal ligation, its duration may be less predictable in this setting and neuromuscular blockade monitoring should be used. Sugammadex has been used to reverse neuromuscular blockade with rocuronium after cesarean delivery, and it can be used to reverse neuromuscular blockade after postpartum tubal sterilization as well. It is compatible with breastfeeding, as transfer into human breast milk is predicted to be minimal and infant enteral absorption unlikely.

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Anesthesia Key

Fastest Anesthesia & Intensive Care & Emergency Medicine Insight Engine

Postpartum Tubal Sterilization EPUB version of this bookEPUB version of this book

AMERICAN SOCIETY OF ANESTHESIOLOGISTS GUIDELINES

SURGICAL CONSIDERATIONS

NONMEDICAL ISSUES

PREOPERATIVE EVALUATION

RISK FOR ASPIRATION

Gastric Emptying, Reflux, and Aspiration Risk

Summary of Aspiration Risk and Prevention

TIMING OF POSTPARTUM TUBAL LIGATION SURGERY

ANESTHETIC MANAGEMENT

Local Anesthesia

General Anesthesia

Related

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Anesthesia Key

Fastest Anesthesia & Intensive Care & Emergency Medicine Insight Engine

Postpartum Tubal Sterilization EPUB version of this bookEPUB version of this book

AMERICAN SOCIETY OF ANESTHESIOLOGISTS GUIDELINES

SURGICAL CONSIDERATIONS

NONMEDICAL ISSUES

PREOPERATIVE EVALUATION

RISK FOR ASPIRATION

Gastric Emptying, Reflux, and Aspiration Risk

Summary of Aspiration Risk and Prevention

TIMING OF POSTPARTUM TUBAL LIGATION SURGERY

ANESTHETIC MANAGEMENT

Local Anesthesia

General Anesthesia

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