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Obstetric sterilization following vaginal or cesarean delivery: A technical update

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GOALS AND OBJECTIVES

After reading this publication, clinicians should be able to:

  • Understand the options available for obstetric sterilization following vaginal or cesarean delivery
  • Describe Filshie clip technology, its correct application, and proper procedure documentation
  • Discuss failure rates for female sterilization
  • Evaluate the findings of the Collaborative Review of Sterilization (CREST) study

Postpartum tubal sterilization is most often performed using the Pomeroy method, a technique that has remained unchanged since its introduction in 1930. Recently introduced clip technology provides an important alternative for clinicians. The Filshie clip—approved for both postpartum and interval use in 1996—offers efficacy rates similar to the Pomeroy method, with potential advantages for physicians and operating room (OR) personnel.

Tubal sterilization—the number one birth control method in the United States—is the choice of 11 million US women, approximately 28% of the women who use contraception1 (TABLE 1). Of this total, half of all tubal sterilization procedures are performed postpartum and are more likely to be performed among women aged 20 to 34 than are interval sterilization procedures.2

In this publication, 3 experts describe their clinical experiences with the Filshie clip and review the medical literature on its use in obstetric sterilization. They offer practical pearls for obstetricians who may want to consider using this technology in their practices. Additionally, they review the Filshie clip and other procedures and devices within the context of the evidence in the medical literature concerning efficacy, ease of use, surgeon time required, and the potential for complications.

TABLE 1

Tubal sterilization procedures in the United States, 1994-1996

Timing/SettingMean Annual No.RateaStandard ErrorDistribution (%)Standard Error
Total684,00011.50.4100na
Postpartum Inpatient (hospital)338,0005.70.349.53.0
Interval345,0005.80.350.6na
Inpatient (hospital)15,0000.20.032.10.3
Outpatient
Hospital ambulatory surgery centerb
Freestanding outpatient surgery center
331,000
288,000
43,000
5.6
4.9
0.7
0.3
0.3
0.1
48.5
42.2
6.3

3.2
0.9
aTubal sterilizations per 1000 women of reproductive age (20-49 years) in the US civilian resident population.
bIncludes procedures performed in hospitals as outpatient procedures.
Reprinted with permission from MacKay AP, et al, Tubal sterilization in the United States, 1994-1996, Family Planning Perspectives, 2001;33(4):162.

Adding the Filshie clip to OR options

DR KAUNITZ: Most ob/gyns have been trained to perform obstetric postpartum sterilization using the Pomeroy method—perhaps that’s why it is often viewed as the only option in this setting. However, at my institution, Shands Jacksonville Medical Center, the Filshie clip is routinely used for postpartum tubal sterilization among the approximately 3000 teaching service deliveries we perform each year.

I became familiar with use of the Filshie clip for laparoscopic sterilization in the mid to late 1990s, following its approval for use in the United States. Once I learned that it was approved for use in C-sections and postpartum procedures and that a short applicator was available (FIGURE), I wanted to try it.

FIGURE The Filshie short applicator

Comparing the Filshie clip vs the Pomeroy method

DR KAUNITZ: As part of a resident research project, we performed a small randomized trial that compared perioperative outcomes with obstetric tubal sterilization using the Pomeroy method versus the Filshie clip.3 In this study, we were particularly interested in the procedure because it alleviates the need for the physician to perform incisions near the engorged broad ligament blood vessels present during pregnancy and delivery. The Filshie clip does not require tubal exteriorization, a potential advantage in obese patients and in those who have tubal adhesions.

Reducing operating time

DR KAUNITZ: Our findings revealed that the Filshie clip was faster and was preferred by the surgeons (TABLE 2). Since then, we’ve kept the short applicator in our labor and delivery OR. We use the Filshie clip not only as the dominant laparoscopic procedure but also increasingly for sterilization performed after childbirth (vaginal and cesarean). The Filshie clip is an appealing option that is becoming more important as the C-section rate continues to rise, and an increasing number of sterilizations may be done at the time of the C-section.

TABLE 2

Results of surgeon and operating room technician questionnaires

Filshie Clip (n =14)Pomeroy (n=15)P Value
Surgical technician questionnaire
Ease of applicator preparation (Filshie) vs ease of preparation for Pomeroy technique1.07±0.271.08±0.28 (n=12).98
Ease of assisting in procedure1.29±0.611.85±1.46 (n=12).64
Surgeon questionnaire
Ease of entry into peritoneal cavity1.71±0.832.5±1.97.51
Ease of tubal identification1.57±0.852.19±2.19.63
Ease of tubal exteriorization3.00±0.442.34±1.21 (n=10).97
Ease of clip/suture application1.07±0.272.29±2.58 (n=14).08
Ease of procedure, overall1.14±0.362.60±1.88.03
Data are presented as mean±standard deviation.
Questionnaire scale from 1 to 5: 1=very easy, 5=very difficult.
Reprinted from Contraception, Vol. 69, Kohaut BA, Musselman BL, Sanchez-Ramos L, Kaunitz AM, Randomized trial to compare perioperative outcomes of Filshie clip vs Pomeroy technique for postpartum and intraoperative cesarean tubal sterilization: a pilot study, pages 267-270. Copyright 2004, with permission from Elsevier.

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