Statement on Anesthesia Support of Postpartum Sterilization

Developed by: Committee on Obstetric Anesthesia
Original Approval: October 23, 2024

Introduction

An estimated 20% of women in the United States choose sterilization via bilateral tubal ligation or salpingectomy as their method of contraception.¹ Sterilization is a permanent, safe and effective method for prevention of future pregnancies. Performing these procedures during the immediate postpartum period is convenient for patients, who are already accessing the healthcare system for labor and delivery. In addition, the procedure is technically less challenging when performed within the first 48 hours after delivery.² Unfortunately, almost 50% of patients who desire permanent sterilization in the postpartum period have their requests unfulfilled.^3-5 While procedure non-completion is multifactorial, up to one third of unfulfilled procedures can be attributed to barriers within the hospital setting, including lack of staffing and unavailability of an operating room, resulting in long wait times.^2,6 These barriers are likely compounded by the perception that sterilization procedures are entirely elective, resulting in lack of prioritization. Given the unpredictability of labor and delivery, scheduling postpartum sterilizations is, by nature, last minute. The American College of Obstetricians and Gynecologists (ACOG) encourages institutions to classify postpartum sterilization procedures as nonelective to reduce the number of unperformed surgical procedures.²

In one study, nearly 50% of women who did not undergo desired postpartum sterilization became pregnant within 1 year, twice that of patients who did not request sterilization.⁷ One reason for this may be barriers to accessing healthcare, from financial concerns to transportation, limiting the patient’s ability to follow-up with providers and to obtain an alternative form of contraception. Unfulfilled sterilization procedures disproportionately affect minorities and those with public health insurance.^2,5,8,9 Given changes in access to abortion care in many states, patients who become pregnant following an unfulfilled sterilization procedure may have limited options. Unintended pregnancies are associated with increased cost, as well as increased rates of maternal and fetal morbidity and mortality.¹⁰ Patients with unfulfilled sterilization procedures report frustration, anger, and dissatisfaction.⁹

Anesthesiologists are uniquely positioned to help facilitate timely completion of postpartum sterilization procedures. Anesthesiologists typically have relationships with operating room staff and knowledge of scheduling policies and procedures that can be very helpful not only in clinical care but also in discussions surrounding development of innovative pathways for postpartum sterilization. Therefore, anesthesiologists should take an active role in the development and implementation of processes to ensure equitable and timely access to these procedures. Anesthesiologists should also support the process of shared decision making and patient autonomy.

Barriers to Achieving Postpartum Sterilization during Delivery Admission

Patient-related Factors

Socioeconomic and demographic factors impact the fulfillment of postpartum sterilization with differences in race, ethnicity, age, income, and insurance status contributing to disparities.^11,12 The presence of certain comorbidities may limit the ability to perform a tubal ligation in the immediate postpartum period. However, comorbidity such as obesity should not automatically restrict access.¹³ ACOG recommends that physicians endeavor to fulfill every patient request for postpartum sterilization.² Prolonged periods of NPO due to extended wait times may also result in patient cancellation of an otherwise desired procedure.⁶

Physician-related Factors

Best practices for discussions regarding postpartum sterilization include the use of shared decision- making and informed consent.² Optimally, the anesthesiology department should ensure the availability of anesthesia personnel to provide care to obstetric patients desiring sterilization in alignment with each patient’s contraceptive goals while simultaneously not compromising the beliefs of individual practitioners.

System-related Factors

Postpartum sterilization rates vary significantly among hospitals.¹⁴ System-related barriers may be multifactorial and include designated urgency of the procedure, lack of operating room availability, and personnel constraints affecting obstetrician, anesthesia and OR staffing.² ACOG has recommended that institutions designate postpartum tubal ligation procedures as nonelective to emphasize their importance and prioritize the completion of the procedure during the delivery hospitalization. Patients should be informed early in the prenatal period if their delivery hospital is restrictive due to religious affiliation or federal, state, or local regulations and should be referred to a facility capable of performing postpartum sterilization if they desire this intervention.² 

Funding and Consent Factors

For patients with federally funded (e.g. Medicaid) medical coverage, lack of the availability of a consent form completed and signed at least 30 days in advance (72 hours in cases of emergency abdominal surgery or premature delivery) has been cited as the most common barrier to access and contributes to disparities in care.⁶ In a single center, retrospective review of unfulfilled postpartum sterilizations at a hospital where there were specially designated obstetric and anesthesia personnel to perform postpartum sterilizations and the Medicaid consent policy was not a factor (institution agreed to perform without reimbursement), 89% of procedures were performed and only 11% were cancelled.¹⁵ This is consistent with previous findings⁶ and supports the feasibility of performing postpartum sterilizations when physicians and systems prioritize this care. Reimbursement for postpartum sterilizations performed for patients covered by Medicaid can also be problematic. Rules and regulations vary among states and the required documentation can be burdensome with denials related to documentation being common. By understanding sociodemographic factors, standardizing early prenatal counseling, and eliminating barriers, physicians and institutions can prioritize this important surgical procedure and create equitable access to care. 

Barriers to Achieving Postpartum Sterilization After Discharge from Delivery Hospitalization 

Many patients who request permanent sterilization in the immediate postpartum period are denied this effective form of birth control for a variety of reasons as discussed above and subsequently are discharged home without the desired procedure. Frustration, anger, dissatisfaction, and anxiety are some of the emotions reported by patients who have unfulfilled sterilization requests.⁹ Studies show that only 39-57% of women who request postpartum sterilization during prenatal contraceptive counseling undergo the procedure while in the hospital. When analyzing completion rates using an interval up to 90 days postpartum, still only 46% of Medicaid enrollees and 65% of privately insured patients who requested postpartum sterilization received the procedure.² Furthermore, studies reveal that 57% of women resume sexual activity six weeks after delivery and 40% of women do not return for a postpartum visit.¹⁶ The consequences of these unmet inpatient requests are unintended pregnancies. Barriers to achieving postpartum sterilization after discharge include inability or lack of attendance at follow-up appointments, childcare obligations, inability to get time off from work, lack of transportation, unstable housing, and communication barriers. 

Resources Needed for Anesthesiologists to Successfully Support Completion of PPBTL

As anesthesiologists seeking to support the choices made by our peripartum patients, we should prepare for the anesthetic and other logistical factors involved in reliably facilitating the provision of postpartum sterilization. Like all patients receiving anesthesia care, there are pre-, intra- and postoperative considerations for patients requesting this procedure that would universally apply regardless of location or institution. Additionally, logistical needs, including staffing and procedure location, require some institution-specific considerations to ensure that postpartum sterilization can be reliably and consistently provided when requested. Federal, state and local requirements and institutional policy must also be considered. If an individual anesthesia professional’s beliefs preclude them from participating in the procedure, an alternate professional should be provided.

Anesthesia for postpartum sterilization should be provided to patients requesting the procedure if the following conditions are met: the peripartum patient is hemodynamically stable, they understand the risks and benefits, delivery has occurred without significant complications, and neonatal assessment has been performed to account for a desire to consider an additional pregnancy.^17,18 Aspiration risk must still be considered, and while gastric emptying may not occur for 4-6 hours following delivery¹⁹ studies have shown that gastric emptying may return to normal within 8 hours post-delivery.²⁰ Patients should be NPO as outlined in the current ASA Practice Guidelines for Obstetric Anesthesia and ASA statements regarding preoperative fasting, and preoperative aspiration prophylaxis should be considered.²¹ If a patient has been receiving anticoagulant medications, confirmation that these medications have been discontinued for the appropriate time period before surgery, and appropriate guidelines followed.

Spinal, epidural or general anesthesia can all be employed safely as the primary anesthetic for postpartum sterilization. The ASA Practice Guidelines for Obstetric Anesthesia do suggest, however, that neuraxial anesthesia may be preferred for most of these surgeries.²² For neuraxial techniques, sensitivity to local anesthetics decreases in postpartum patients compared to pregnant patients, necessitating higher doses (up to 30%) within 8-24 hours following delivery.²³ The presence of preeclampsia does not necessarily preclude the use of a neuraxial anesthetic, as research has shown a lack of pronounced hemodynamic consequences in the setting of spinal or epidural anesthesia for postpartum sterilization.²⁴ A functional in-situ labor epidural catheter can be utilized to provide anesthesia for postpartum sterilization; however, reactivation is most successful when closest to delivery, and is highest within 1-4 hours after delivery.²⁵ Other studies have shown a significant decrease in successful utilization of an in-situ epidural catheter 24 hours following delivery compared to those activated within the first 24 hours.²⁶ In the setting of general anesthesia for postpartum sterilization, providers must recognize that airway changes may persist in the immediate post-partum period or worsen, especially following pushing during the second stage of labor.²⁷ Additionally, propofol may yield advantages as a primary anesthetic agent given its lack of tocolytic properties as opposed to volatile anesthetics. Neuraxial morphine is effective for postsurgical analgesia but requires increased monitoring and may prolong hospitalization.²⁸ Generally, intravenous or oral non-steroidal anti-inflammatory agents with small doses of parenteral opioids provide sufficient postoperative analgesia.
 
Logistical challenges account for a large portion of unmet requests for postpartum sterilization. Lack of operating room space, nursing, surgical technologist or unavailability of anesthesia personnel accounts for 10-33% of unfulfilled requests for the procedure. Adequate support from the institution to ensure availability of anesthesia personnel to perform postpartum sterilizations is needed. Potential strategies to overcome the logistical challenges are discussed below. 

Innovative Strategies for Overcoming Logistical Issues in Achieving Postpartum Sterilization

Access barriers do exist with regard to completing postpartum sterilization procedures, and innovative strategies are needed to address the logistical challenges contributing to these barriers. As mentioned previously, institutions should consider designating postpartum sterilizations as nonelective procedures. Just this change in designated urgency could play a significant role in completing these surgeries. Chronic medical conditions and practitioner bias can also lead to unfulfilled sterilization requests. Strategies to overcome these barriers involve challenging misconceptions about obesity-related risks, emphasizing shared decision-making, and addressing biases and disparities that disproportionately affect individuals of color and low socioeconomic status.

Inadequate hospital resources play a significant role in unfulfilled postpartum sterilizations. While many institutions perform the procedures in operating rooms located in the labor and delivery unit, facilities could consider instead performing these surgeries in the main operating room environment. This would ameliorate the strain placed on labor and delivery units that often have more limited staffing and resources compared to the main operating rooms. Such a strategy has the potential to increase postpartum sterilization completion rates while allowing resources on the labor and delivery unit to be devoted to patients in labor and undergoing cesarean delivery. Another potential strategy at institutions that prefer to perform the procedures on the labor and delivery unit is to have a designated operating room team to perform the postpartum sterilizations. At one institution the availability of such a team contributed to nearly 90% of all requested postpartum sterilization procedures being performed.¹⁵ Nights and weekends can present challenges to providing postpartum sterilization services as many units will have reduced staffing compared to weekdays.²⁹ Temporary staffing increases to meet the need of fulfilling postpartum sterilization procedures is another possible strategy. Offering incentive pay to physicians and staff to ensure availability could be considered. Implementation of an expedited outpatient surgical scheduling system could also assist in removing barriers. With such a system those patients who could not have the surgery performed during delivery hospitalization will have a surgery date scheduled and preoperative instructions reviewed prior to discharge.³⁰ Along with follow-up telephone conversations after discharge, the probability of patients receiving their desired postpartum sterilization before an unintended pregnancy occurs would likely be increased with this scheduling system.

Complex consent requirements have hindered access to postpartum sterilization. Proposed solutions include revising hospital consent forms for readability, creating standardized decision support tools, developing multilingual forms, and redefining time frames for which a hospital consent form is valid. It is unlikely the federally required consent form for patients insured by Medicaid will be changed soon. However, electronic health records integration can enhance accessibility and sharing of these consents across institutions. Federal, state, and local requirements and institutional policies regarding postpartum sterilization should also be considered.

In conclusion, overcoming the many challenges in achieving postpartum sterilization procedures requires a multifaceted approach. Anesthesiologists can play an important role in overcoming some of these barriers. Addressing biases, improving hospital resources, and streamlining consent processes through innovative strategies can enhance access to this important patient choice of contraceptive method, ensuring fair and equitable care for all individuals, regardless of socioeconomic status or background.

The following recommendations are suggested:

1. Anesthesiology departments should help facilitate postpartum sterilization requests during delivery hospitalization and work with obstetric, nursing, operating room and administrative colleagues to secure adequate resources to accomplish these sterilizations during the delivery hospitalization.
2. Efforts should be made to minimize time periods between delivery and a postpartum sterilization procedure.
3. NPO and aspiration prophylaxis recommendations as outlined in the current ASA Practice Guidelines for Obstetric Anesthesia and ASA statements (https://www.asahq.org/standards-and-practice-parameters) regarding preoperative fasting31 should be followed when performing these procedures.
4. Individual patient factors should be considered and shared decision-making utilized when determining anesthetic technique(s) for the procedure.

References:

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