|Year : 2011 | Volume
| Issue : 1 | Page : 1-2
The Association of Obstetric Anaesthesiologists guidelines for anaesthetic management of patients undergoing tubal ligation
Association of Obstetric Anaesthesiologists
Chief Editor, Journal of Obstetric Anaesthesia and Critical Care, Room No. 5020, Department of Anaesthesiology and Intensive Care, AIIMS, Ansari Nagar, New Delhi - 110 029, India
|Date of Web Publication||25-Aug-2011|
Association of Obstetric Anaesthesiologists
Chief Editor, Journal of Obstetric Anaesthesia and Critical Care, Room No. 5020, Department of Anaesthesiology and Intensive Care, AIIMS, Ansari Nagar, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Association of Obstetric Anaesthesiologists. The Association of Obstetric Anaesthesiologists guidelines for anaesthetic management of patients undergoing tubal ligation. J Obstet Anaesth Crit Care 2011;1:1-2
|How to cite this URL:|
Association of Obstetric Anaesthesiologists. The Association of Obstetric Anaesthesiologists guidelines for anaesthetic management of patients undergoing tubal ligation. J Obstet Anaesth Crit Care [serial online] 2011 [cited 2021 Jan 24];1:1-2. Available from: https://www.joacc.com/text.asp?2011/1/1/1/84247
The following are suggested evidence-based guidelines only and are intended to provide quality patient care:
- The patients scheduled for Tubal Ligation (TL) under anaesthesia - general or regional - should undergo a thorough pre anaesthetic evaluation and an informed written consent should be obtained before surgery. A detailed airway examination is mandatory to identify patients with a difficult airway. This should be similar to the evaluation done for any surgical procedure performed under anaesthesia.
- In case TL is planned within a few days (1−7 days) of uncomplicated delivery (in parturients without any medical/obstetric problems and undergoing regular antenatal checks) repeat laboratory work-up may not be necessary. In case the procedure is planned after this period, standard clinical evaluation and investigation protocols for anaesthesia should be followed. Basic investigations should also be done in case the parturient has had no investigations / laboratory work-up during her pregnancy.
- Post partum TL should be postponed whenever there is evidence of hemodynamic instability due to any cause, refractory hypertension, moderate-to-severe preeclampsia, severe anemia, or sepsis. Counseling regarding alternative methods of contraception should be provided to these parturients.
- Tubal sterilization for patients with complicated medical / cardiac diseases should be carried out in centers with facilities for invasive monitoring and multi disciplinary support. (In such a scenario, alternate contraception techniques should be offered including motivation of the husband for undergoing vasectomy).
- All post partum patients need to fast for 6−8 hours prior to TL. Aspiration prophylaxis in the form of non particulate antacids, H2 receptor antagonists and/or metoclopramide should be administered to these patients as per standard protocols. Soon after delivery, the period of increased risk of aspiration during anaesthesia is debatable, hence in the first 48 hours all patients should receive aspiration prophylaxis.
- The operating room should be well equipped (anaesthesia machine, oxygen supply, emergency drugs, complete set of resuscitation equipment, etc.) and should have all essential government licenses / clearances to carry out such procedures.
- Intraoperative monitoring in the form of electrocardiogram, non invasive blood pressure and pulse oximetry are essential. Capnography is desirable for all procedures being carried out under general anaesthesia.
- Anaesthetic technique chosen should be individualized in all cases. The choice should depend on the anaesthetic and obstetric risk factors, patient's choice and the preference of the surgery team. Options vary from regional anaesthesia (spinal / epidural) with sedation to general anaesthetic techniques. Neuraxial techniques are preferred over general anaesthesia for most postpartum tubal ligations. 
- Premedication is not mandatory. Reassurance and proper explanation of the procedure usually suffice.
- General anaesthesia: Balanced general anaesthesia may be safely administered, but the anaesthesiologist must take into account problems associated with airway management in this group of patients. It must be remembered that soon after delivery the patient is at increased risk of aspiration and endotracheal intubation is the safest option if a general anaesthetic is being planned. Currently, supra glottic airway devices have also been used for administration of general anaesthesia for post partum tubal ligation and gynecological laparoscopic surgery, , and as rescue devices for airway management. Such devices should preferably have esophageal drain tube to allow gastric drainage.
- Epidural anaesthesia: In case epidural catheter was placed for labor analgesia and it had provided optimum pain relief during and after labor, the same catheter can be used for tubal ligation scheduled within two days. It is not advisable to keep the catheter for more than 72 hours. Epidural catheters placed for labor may fail if post delivery time interval is prolonged. ,, Either lidocaine 2% or bupivacaine 0.5% can be used to achieve appropriate regional block for TL up to T 8 dermatome. Fluid administration and monitoring should be as per standard protocols.
- Spinal anaesthesia: Spinal anaesthetic dose requirements are decreased during pregnancy and return to non pregnant levels 36−48 hours after delivery.  Hyperbaric bupivacaine (0.5%; 1.6 to 2.0 ml) is commonly used. Lignocaine 5% for spinal use has not been withdrawn officially but is associated with serious side effects in some patients and is best avoided. It is recommended that adding lipid-soluble opioids, such as fentanyl (15−25 μg), may improve the efficacy of small dose of bupivacaine. However, if an opioid is added, treatments for related complications (e.g., pruritus, nausea, respiratory depression) should be available. Fluid administration and monitoring should be as per standard protocols.
- Local anaesthesia: Local infiltration of lignocaine with sedation is still used for tubal sterilizations in many centers in the developing world. This practice should be discouraged as it may not provide appropriate anaesthesia/analgesia to parturients patients and exposes her to additional complications. 
- All patients should be monitored after tubal ligation.  Monitoring comprises of level of sedation, pulse rate, blood pressure, respiratory rate and surgical site bleeding, as and when required/ at least every 15 minutes in the first hour and hourly thereafter for four hours. The discharge criteria of all such patients should be the one which is being followed in the respective centers as per protocols and in case there is none it is suggested that the Modified Alderte or PADSS  should be followed as it is simple and easy to practice.
- It is mandatory that the anaesthesiologist involved in the procedure maintains a proper record of the pre operative assessment, intraoperative monitoring and ensures that there is a proper record of the discharge status.
| Acknowledgement|| |
The editorial board of the journal and the executive members of the AOA acknowledge the efforts made by Dr Indu Sen from Chandigarh in framing these guidelines.
| References|| |
|1.||American Society of Anaesthesiologists Task Force on Obstetric Anaesthesia. Practice guidelines for obstetric anaesthesia: An updated report by the American Society of Anaesthesiologists Task Force on Obstetric Anaesthesia. Anaesthesiology 2007;106:843-63. |
|2.||Evans NR, Skowno JJ, Bennett PJ, James MF, Dyer RA. A prospective observational study of the use of the Proseal laryngeal mask airway for postpartum tubal ligation. Int J Obstet Anesth 2005;14:90-5. |
|3.||Roth H, Genzwuerker HV, Rothhaas A, Finteis T, Schmeck J. The ProSeal laryngeal mask airway and the laryngeal tube Suction for ventilation in gynaecological patients undergoing laparoscopic surgery. Eur J Anaesthesiol 2005;22:117-22. |
|4.||Viscomi CM, Rathmell JP. Labor epidural catheter reactivation or spinal anaesthesia for delayed postpartum tubal ligation: A cost comparison. J Clin Anesth 1995;7:380-3. |
|5.||Vincent RD, Reid RW. Epidural anaesthesia for postpartum tubal ligation using epidural catheters placed during labor. J Clin Anesth 1993;5:289-91. |
|6.||Goodman EJ, Dumas SD. The rate of successful reactivation of labor epidural catheters for postpartum tubal ligation surgery. Reg Anesth Pain Med 1998;23:258-61. |
|7.||Bucklin BA. Postpartum Tubal Ligation: Timing and Other Anaesthetic Considerations. Clin Obstet Gynecol 2003;43:657-66. |
|8.||Manual "Standards for Female and Male Sterilization Services" by Research Studies and Standards Division of the Ministry of Health and Family Welfare, Government of India; 2006. p. 1-92. |
|9.||Chung F, Chan VW, Ong D. A post-anaesthetic discharge scoring system for home readiness after ambulatory surgery. J Clin Anesth 1995;7:500-6. |