CURRENT TRENDS
Bilateral
Uterine
artery
ligation
plus B-
Lynch
procedure
for atonic
postpartum hemorrhage with placenta accreta
Corrected Proof
Abstract
Objective
To assess the effectiveness of bilateral uterine artery ligation followed by B-Lynch compression
suturing in women with atonic postpartum hemorrhage and placental site bleeding due to adherent
placenta accreta.
Method
This protocol was followed in 26 women undergoing cesarean delivery for placenta accreta.
Results
Two women died from disseminated intravascular coagulopathy. In the remaining 24 women, placental
remnants completely disappeared within 8months and ovulation resumed after a mean± SD of 51.6 ±
3.2 days. Moreover, 18 women (75%) became pregnant within 12months.
Conclusion
Atonic postpartum hemorrhage and placental site bleeding due to adherent placenta accreta can be
safely controlled by bilateral uterine artery ligation followed by B-Lynch compression suturing in
women who desire to remain fertile.
STATISTICS
Currently, about 700,000 of these procedures are performed each year in
the United States. Half are performed right after a woman gives birth. The rest
are elective procedures performed as a one-day operation in an outpatient
clinic. Eleven million US women aged 15-44 years rely on sterilization as a means
of birth control to prevent pregnancy. More than 190 million couples worldwide
use surgical sterilization as a safe and reliable method of permanent birth control.
Recently, one tubal reversal center conducted a study of over 5000 women
on the subject of pregnancy rates following tubal ligation reversal surgery. These
women were the patients of this center from 2000 to 2008 which allowed close to
one year for collection of data after tubal reversal surgeries in 2008. The
pregnancy statistics available from this study will allow any woman considering
reversing her tubal ligation to know what to expect depending upon different
criteria.
DEFINITION
Tubal sterilization is surgery to block a woman's fallopian tubes. Tubal
sterilization is a permanent form of birth control. After this procedure, eggs cannot
move from the ovary through the tubes (a woman has two fallopian tubes), and
eventually to the uterus. Also, sperm cannot reach the egg in the fallopian tube
after it is released by the ovary. Thus, pregnancy is prevented.
This procedure is also called tubal ligation or you are said to have your "tubes
tied." More formally, it is known as bilateral tubal ligation (BTL).
Advantages and disadvantages
Tubal ligation is a more major surgery than vasectomy, and carries greater risks.
Postoperative complications are more likely than with vasectomy, and more costly.
For instance, in industrialized nations, mortality is 4 per 100,000 tubal ligations,
versus 0.1 per 100,000 vasectomies.
Tubal ligation has a larger initial cost than other contraceptive methods.
Typically vasectomies are more cost-effective than tubal ligation because they are
less expensive. It may take more than a decade of use for tubal ligation to
become as cost-effective as other highly effective, long term methods like IUD or
implant. Continued method costs or costs from unintended pregnancies make
many other methods as or more costly than tubal ligation if used for several
years. The cost of tubal ligation is reduced if it is performed during a cesarean
section since the tubes are already exposed during the laparotomy.
Description
Tubal ligation is done in a hospital or outpatient clinic. You may receive general
anesthesia. This will make you unconscious and unable to feel pain. Or, you may
have local anesthesia (awake and unable to feel pain) or spinal anesthesia (awake
but unable feel pain). The procedure takes about 30 minutes.
• Your surgeon will make 1 or 2 small incisions (cuts) in your belly, usually
around the belly button. Gas may be pumped into your belly to expand it.
This helps your surgeon see your uterus and fallopian tubes.
• Your surgeon will insert a laparoscope, a narrow tube with a tiny camera on
the end into your pelvic area. Instruments to tie your tubes will be sent
through the laparoscope.
• The tubes are either cauterized (burned shut) or clamped off with a small
clip, a ring, or rubber bands.
Tubal ligation can also be done right after you have a baby through the vagina or
during a cesarean section.
PROCEDURE
There are mainly four occlusion methods for tubal ligation, typically carried out on
the isthmic portion of the fallopian tube, that is, the thin portion of the tube
closest to the uterus:
• Partial salpingectomy, being the most common occlusion method. The
fallopian tubes are cut and realigned by suture in a way not allowing free
passage. The Pomeroy technique, is a widely used version of partial
salpingectomy, involving tying a small loop of the tube by suture and
cutting off the top segment of the loop. It can easily be applied via
laparoscopy. Partial salpingectomy is considered safe, effective and easy to
learn. It does not require any special equipment to perform; it can be done
with only scissors and suture. Partial salpingectomy is not generally used
with laparoscopy.
• Clips: Clips clamp the tubes and inhibits blood flow to the portion, causing a
small amount of scarring or fibrosis, in turn, preventing fertilization. The
most commonly used clips are the Filshie clip, made of titanium, and the
Wolf clip (or "Hulka clip"), made of plastic. Clips are simple to insert, but
require a special tool to put in place.
• Silicone rings: Tubal rings, similarly to clips, block the tubes mechanically.
It encircles a small loop of the fallopian tube, blocking blood supply to that
small loop, resulting in scarring that blocks passage of the sperm or egg. A
commonly used type of ring is the Yoon Ring, made of silicone.
• Electrocoagulation or cauterization: Electric current coagulates or burns
a small portion of each fallopian tube. It mostly uses bipolar coagulation,
where electric current enters and leaves through two ends of a forceps
applied to the tubes. Bipolar coagulation is safer, but slightly less effective
than unipolar coagulation, which involves the current leaving through an
electrode placed under the thigh.It is usually done via laparoscopy.
PREPARATION
While you are under anesthesia, one or two small incisions (cuts) are made
in the abdomen (usually near the navel), and a device similar to a small telescope
on a flexible tube (called a laparoscope) is inserted.
Using instruments that are inserted through the laparoscope, the tubes
(fallopian tubes) are coagulated (burned), sealed shut with cautery, or a small clip
is placed on the tube. The skin incision is then closed with a few stitches. You are
usually feeling well enough to go home from the outpatient surgery center in a
few hours.
Your health care provider may prescribe pain medications to help you
manage the pain, if any.
Most women return to normal activities, including work, in a few days,
although you may be advised not to exercise for several days. You may resume
sexual intercourse when you feel ready.
Tubal ligation can also be performed immediately after childbirth through a
small incision near the navel or during a Cesarean delivery.
Currently, laparoscopy (bipolar laparoscopy, Falope ring, Filshie clip) is the
most popular method of female sterilization in nonpregnant women. Periumbilical
minilaparotomy (Pomeroy, Parkland) is the most common procedure right after
childbirth.
A new device acts much like tubal sterilization by blocking the fallopian
tubes. The Food and Drug Administration has approved a small metallic implant
(called the Essure System) that is placed into the fallopian tubes of women who
wish to be permanently sterilized. Unlike other currently available tubal
sterilization procedures for women, placement of the device does not require an
incision or general anesthesia.
During the Essure procedure, your health care provider inserts an
obstructive device into each of the 2 fallopian tubes at the time of hysteroscopy.
This is done with a special catheter that is inserted through the vagina into the
uterus and then into the fallopian tube. The device works by inducing scar tissue
to form over the implant, blocking the fallopian tube and preventing fertilization of
the egg by the sperm.
RISKS
Risks for any surgery are:
• Bleeding
• Infection
Risks for any anesthesia are:
• Allergic reactions to medicines
• Breathing problems or pneumonia
• Heart problems
Risks for tubal ligation are:
• Incomplete closing of the tubes, which could make pregnancy still possible.
About 1 out of 200 women who have had tubal ligation get pregnant later.
• Increased risk of a tubal (ectopic) pregnancy if pregnancy occurs after a
tubal ligation
• Injury to nearby organs or tissues from surgical instruments
Before the Procedure
Always tell your doctor or nurse:
• If you are or could be pregnant
• What drugs you are taking, even drugs, herbs, or supplements you bought
without a prescription
During the days before your surgery:
• You may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), warfarin
(Coumadin), and any other drugs that make it hard for your blood to clot.
• Ask your doctor which drugs you should still take on the day of your surgery.
• If you smoke, try to stop. Ask your doctor or nurse for help quitting.
On the day of your surgery:
• You will usually be asked not to drink or eat anything after midnight the
night before your surgery, or 8 hours before the time of your surgery.
• Take the drugs your doctor told you to take with a small sip of water.
• Your doctor or nurse will tell you when to arrive at the hospital or clinic.
NURSING CARE MANAGEMENT
• Two stressors the patient is recovering from: surgery and anesthesia.
• After the surgery is completed and dressing applied, the patient’s endotracheal tube is
removed. Transferred to recovery room by circulating nurse and CRNA. Those who do
not go to PACU include surgery under local (they can go straight home or to Phase II)
and those going directly to critical care area.
• Close observation. 1:1 or 1:2.
• Standard and emergency equipment are present (like ICU).
• Almost all receive oxygen
• Monitoring is individualized to patient need and type of surgery. Continuous, then up to
q15m: EKG, NIBP, pulse oximetry, Intake & output
• All preop orders are discontinued postop, rewritten in PACU (vitals, position,
medications, IV, type of PO intake, activity, diagnostic tests, dressing changes).
Angeles University Foundation
Angeles City
College of Nursing
A.Y. 2009-2010
INDIVIDUAL CASE REPORT:
BILATERAL TUBAL
LIGATION
In Partial Fulfillment of the Requirements needed in NCM 102 Related
Learning Experience:
Submitted by:
BSN III - 9
Group # 34
Silva, Melissa Joie M.
Submitted to:
Ma’am Rochelle Gumabon, RN
Date:
December 17, 2009
