Postpartum+Tubal+Ligation

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** CCRMC OBGYN **** Prenatal Guideline ** Consultation available 24 hours per day from OB on-call at 925-370-5608 or via page/amion, via inbasket to OB dept member or by calling Perinatologist at 510-444-0790 during the day and 510-204-1572 after hours. Consultation appointments or transfer of care to more experienced prenatal clinician available at major clinics sites—see consultation guidelines for more information.

** Postpartum Tubal Ligation (PPTL) ** Discuss the option of sterilization preferably before the 3rd trimester to allow time for consideration by patient. Have her sign the consent after 20 weeks and ideally before 34 weeks EGA, if interested. Consider surgical risks, failure rate, **lack of reversibility** and alternative contraceptive methods (including vasectomy) in the discussion. She will no longer be eligible for Family Pact state coverage after the tubal ligation so she will lose this coverage for pap smears and follow up. She can always change her mind and decline anytime before the surgery. She will need to sign a second surgical consent just before the procedure. She must be at least 21 to sign the consent for sterilization per state law. Patients who are quite young despite being over 21 should be counseled regarding both a higher long term dissatisfaction rate with sterilization as well as a higher failure rate. LARC's may be a better option. Medi-Cal (including CCHP Medi-Cal) requires a 30 day interval between signing the PPTL consent and EDD. Non Medi-Cal funding requires only 3 days. This situation occurs less frequently and requires a different tubal consent. Both consents can be found in the OBGYN consents on I-site with instructions assisting with which consent to use (star icon). In doubt, use PM 330. State law requires at least 3 days from signing the tubal papers. The consent is only good for 180 days so avoid signing in the first trimester. Please make sure that the consent is filled out correctly and completely— the entire left column and the first half of the right column. Double check dates and make sure both you and the patient have signed. Make sure the consent is scanned into media and that the patient has a copy with them. It can get complicated at times, particularly if the tubal consent is signed late in gestation, but all of the following situations will allow for PPTL: PPTLs will usually be done during the patient's postpartum stay assuming no intrapartum complications, frequently in a 7 am OR slot on postpartum day 1. Rarely, patients desiring PPTL will be unable to have the procedure due to scheduling issues, or intrapartum complications. Interval laparoscopic tubal fulguration or Essure after 6 wks postpartum is a less convenient but an available alternative in this setting. A visit to women's health clinic to allow family PACT coverage is usually required for those whose coverage was limited to the pregnancy.
 * patients delivering > 30 days after consent
 * patients delivering early, < 30 days after consent, if consent is > 30 days before EDD
 * patients >3 days from consent if going to surgery for another reason e.g. cesarean

Patients with very high BMI (e.g. > 50), or prior abdominal surgeries, especially with mesh, should consider interval Essure or alternative LARC to minimize surgical risk. If BTL desired, sign 30 day consent in case cesarean needed so BTL can be done at same time.