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MRCOG PART 2 SBAs and EMQs

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Essay 306 - Lap steri

Posted by Akanksha G.
A healthy 28 year old mother of 2 children has been referred because she requests laparoscopic sterilisation. She had two vaginal deliveries. (a) Discuss your assessment and counselling of this woman [10 marks].
Assessment of this woman would include enquiring obstetric history of no of pregnancies and their outcome, the mode of delivery in the previous 2 pregnancies, age of the youngest child, outcome of the immediate antecedent pregnancy and how long back was it. A detailed menstrual history, regularity, associated menorrhage, dysmenorrhoea, last menstrual period. a past history of surgeries, peritonitis, inflammatory bowel disease, ruptured ectopic (these increase the possibility of intraabdominal adhesions) history of any contraceptive usage in the past and her acceptance or side effects of the same. history of cardiorespiratoey illnes which may be significant for anesthetic management my examination would include BMI, vitals (pulse and BP) screening cardiovascular and respiratory examination, abdominal examination for scars, any palpable mass. a perspeculum and pervaginal examination to dtect any clinical abnormality. investigation would include, FBC, HIV , Hbsag and HCV testing.
i would prefer to counsel the women along with her partner if possible. i would inform them that sterilization can include tubal ligation in the lady or vasectomy in the partner. that tubal ligation carries a failure rate of 1 in 200 vs 1in 2000 for vasectomy and also risks of surgery are less with vasectomy. i would provide the woman with options of other long term contraceptives like intrauterine copper devises(licensed for use for 8 yrs) and intrauterine system (especially in the presence of menorrhagia),
implants advantages and disadvantages of the same. i would tell her that though sterilization is intended to be irriversible, she may opt for reversal in the future following which she can expect an intrauterine pregnancy rate of 30-60 % and ectopic of 0-7%. i would inform her that cost ivf procedures if required due to failure of reversal are not covered by NHS.
b) Outline the information that you will discuss with the woman in order to obtain informed consent for laparoscopic sterilisation [6 marks].
i would tell her that lap sterilization involves aplication of clip(filchie clips) about 1-2 cm from the uterine end of the fallopian tube so that the lumen of the tube is complletely occluded. i will tell her that this procedure carries a failure rate of 1 in 200 life time. and failure is higher if preformed in the post partum period.
i will discuss with her the risks associated with entry risk of bowel injury of 0.4/1000, risk of vessel injury 0.2/1000. these risks higher in obese women and women with previous surgeries. and that in such a event she might require a laparotomy with or without blood trasfusion.
i i would also discuss with her regarding the method entry in the event of failure with laparoscopy, ie minilap.
(c) She is listed for laparoscopic sterilisation and attends as a day case. Discuss your pre-operative assessment [4 marks].
review case notes, and rule out any concurrennt ilness which amy nescessitate an additional proecedure or a more suitable treatment option. i will enquire if she has developed any new illness during the waiting period like cough, cold which may affect the anesthetic management. i would note the last menstrual period, ensure that the patient has used effective contraception till date. if patient not in the immediate post menstrual phase and not used contraception defer the porcedure till nest mensus and advise to follow contraception till the surgery date. a urine pregancy test, may be negative in the luteal phase pregnancy, routine uterine curettage for disruption of possible luteal pregnancy not advocated. ensure that the women has understood the advantages, disadvantages, complications of the procedure, and answer any quuiries.
Posted by shipra K.
A) Assessment starts by taking a detailed history as to the ages of the two children and that she is in a stable relationship(if children too young or patient not in stable relationship then tubal ligation is probably not the best method), A history of.previous pregnancy losses or terminations to complete her obstetrical history..Method of contraception she is using .Menstrual history which would includes her last menstrual period ,previous menstrual cycles including the cycle length ,duration of bleeding,flow dysmenorrhoea.Any medical disorders she suffering from like heart disease,any chronic obstructive lung disease which would make her high risk for pnuemoperitoneum and general anaesthesia.Any previous surgeries especially abdominal surgery where adhesions might make injuries more common and entry into abdomen difficult or chances of conversion to a laparotomy.
Examination would include pulse rate,respiratory rate,blood pressure,temperature,a thorough cardiovascular and respiratory system examination.Per abdomen examination to see for any scars of previous surgeries ,any lump abdomen..A per speculum and per vaginum examination to note for features of PID which should be treated before surgery.the size of uterus if enlarged could be because of pregnancy or fibroid( and if more than 16 weeks increased chances of uterine perforation).or any adenexal mass to be noted.
Investigations would include FBC,urea & electrolytes,CXR(P-A) view,urine routine microscopic.
Pre operative assessment with the anaesthetist should be arranged.
Counselling would include discussion regarding other methods of contraception especially if the children are too young then patient can be advised long term methods of contraception like Cu-T 380 rather than going for tubal ligation. It is a permanent method of contraception and is irreversible(success rate for recanalization surgery is very poor) in case she desires pregnancy later she might have to undergo IVF
The sterilization procedure involves placing clips (flische) clips on the tubes.
She should continue with the contraceptive method she is practicing till the menstrual cycle after sterilization procedure.
There is 1% chance of failure of tubal ligation and this could be because of continuation of a luteal phase pregnancy therefore it is important for her to continue with the contraception and it would be better if she undergoes the procedure in the immediate postmenstrual phase.
Also that there is no evidence that sterilization causes menorrhagia.
Written material should be provided to the the patient.
B)Before taking informed consent it should be explained that there are chances of failure of the procedure.In case failure occurs then there are high chances that it could be an ectopic pregnancy.That there can be complications like bowel perforation,vascular injury ,uterine perforation and failure of entry in abdomen.Also there are chances conversion to laparotomy There are 39% chances of anaesthetic complications. Written informed consent should be taken on a consent form which clearly explains the complications associated with surgery.
C)On the day of the surgery a urine pregnancy test done to rule out pregnancy.in case the patient is pregnant the surgery should be postponed to give her time to decide if she wants to continue with the pregnancy or not,also explaining that interval tubal ligation has less chances of failure than the procedure if done with termination of pregnancy.Patients sexual history to be taken if she has had unprotected intercourse after her last periods again the surgery should be postponed.It should be made clear that patient has not complied with the instructions given to her and that she could be pregnant.Patients menstrual history should be take and any history of delayed periods the procedure should be postponed for a better time that is after periods in the follicular phase of the cycle.
Posted by Sophia Y.
(a) Discuss your assessment and counselling of this woman [10 marks].

My initial assessment will include asking her & exploring why she wants to be sterilised. I will ask her how long she has been considering for a sterilisation and whether she is sure her family is complete. I will ask her how long she has been with her partner and whether it is a stable relationship as regrets rate of being sterilised is higher if she is in an unstable relationship. I will ask her a detailed contraception history - what contraception she has been using now & before, reasons of stopping and problems encounter. I will ask her menstrual history, her last menstrual period, problems with menorrhagia or dysmenorrhea or endometriosis as these symptoms may become worse after sterilisation and stoppage of hormonal contraception. I will also ask presence of chlamydia infection or pelvic inflammatory disease, abdominal surgery or pelvic surgery where adhesions might be formed which can increase risk of surgical complications.

I will check her body mass index (BMI) as risk of visceral injury is higher in women with extreme BMI. In addition BMI & blood pressure should be checked as part of pre-operative assessment. I will examine her abdomen to exclude any pelvic mass.

I will explain to her very sympathetically that risk of regrets is high in women who has sterilisation before 30 years old. I will counsel her about alternative contraceptive methods. These include combined oral contraceptive pill and progeston-only pill. I will also discuss about long acting reversible contraception (LARC) - depo provera, implanon, mirena coil and intrauterine contraceptive device (IUCD). All of them are very effective & reliable. Depo provera requires injection every 12 weeks. Implanon and IUCD can be removed after 3 & 7 years, respectively. Mirena coil can be removed after 5 years with failure rate similar to being sterilised laparoscopically. Alternatively her partner can consider a vasectomy which has a lower complication and failure rate than sterilisation. She should consider using reliable contraception eg LARC and return to us after 30 years old if she still wants to be sterilised. In addition she should be counselled about menstrual symptoms developed after sterilisation as they might have been well controlled by hormonal aspects of the contraception. Therefore she might have to re-start these treatment after being sterilised. Furthermore she should be counselled about perceiving sterilisation as permanent contraception to unwanted fertility. Future reversal sterilisation will unlikely be funded by the NHS. The success rate of pregnancy can be low.
If she still wants to be sterilised after being counselled properly, her wish should be respected. I will put her on waiting list for laparoscopic sterilisation. She will be given a written information leaflet about the procedure.

(b) Outline the information that you will discuss with the woman in order to obtain informed consent for laparoscopic sterilisation [6 marks].

I will explain to her that sterilisation will involve putting a clip (filshie clip) onto each fallopian tube. It is a laparoscopic approach with small incisions on abdomen. The intended benefit is to achieve permanent contraption. She should be aware risk of surgical complications including bleeding, infection, anaesthetics, risk of injury to bowel, bladder, major blood vessels and ureter. She should be counselled about risk of failure (1/200) and increased risk of ectopic pregnancy if she becomes pregnant after sterilisation. She should also be aware about risk of laparotomy if laparoscopic approach fails or surgical complications require exploration. I will also counsel her about risk of shoulder tip pain & incision hernia formation. I will also consent her for blood transfusion if needed.

I will offer to give her the copy of signed consent form.


(c) She is listed for laparoscopic sterilisation and attends as a day case. Discuss your pre-operative assessment [4 marks].

I will assess her risk of being pregnant. This will include asking her when her last menstrual period was, what contraception she has been using and presence of any unprotected sexual intercourse. I will also ensure she has a negative urine pregnancy test before the surgery. I will also ensure she still wants to be sterilised.
Posted by H H.
I would ask of her reason for requesting sterilisation, as it is considered to be a permanent method of contraception(despite reversal can be done). I would ask her of her LMP and regularity of her period. Would ask of previous contraception she used ,of its side effects and if failures occurred from them resulting in her pregnancies being unplanned or termination of pregnancies that she did not mention in her history(sympathetic approach in taking history taking her rapport).
Would enquire of previous abdominal surgeries and reason.
Would enquire of social history regarding presence of a permanent loving relationship, her family and partner support,and of her smoking,alcohol and illicit drug habits.
Would tell her what the procedure entails,with benfits and risks. Would tell her that there is failure rate of one pregnancy in 200 procedures and that if it occurs there is a high chance of being ectopic.
Would counsel her regarding complications,frequent and serious side effects of the procedure and additional procedures that might be needed . These will be discussed while taking her consent. Will give her written information.
Would measure her BMI and examine abdomen for scar sites of previous operations and presence of masses.


B) Will discuss what the procedure entails, abdominal procedure done under general anesthesia,abodomen scoped and tubes visualized and clips applied to occlude it.Would discuss benfits,,efficient way of permanent contraception , serious risks, uterine perforation , visceral injury,bleeding, frequent risks , shoulder pain ,wound discomfort and ifection at wound site. Would discuss additional procedures in case of failure of entery into abdomen ,need for minilaparotomy, correction of visceral injury or arrest of bleeding ,which would need laparotomy.
Would tell her that it is done under general anesthesia and would be done by an experienced person. Would be happy to answer any enquiries and discuss things she would not like to do without previous consent (eg jahovahs witness). Would take her signature.


C) Preoperative assessment would include asking her of her LMP and of any possibility of being pregnant. Would ask her of her contraception up to date and date of last sexual act. The operation can be rescheduled if in suspicion of pregnancy as serum pregnancy would not be cofirmatory if negative.
Would do FBC and blood group and save.
Would ask for anesthetic review.
Would revise her consent with the patient and see if still sure of her decision, and sign it.

Posted by C P.
C

(a)
In the history I will ask about her menstrual cycle. Her LMP, regularity of her period, duration of bleeding, dysmenorrhoea, or dysperiunia. In case if she has any of the above problems she needs counselling. There are other methods of LARC which is almost equitant to sterilisation which can resolve menstrual related problems.
Her contraceptive history needs evaluation. It is important to know why she has decided to go for laparoscopic sterilisation. If she had undergone any surgery before I will ask the details about it. If she has a midline scar either Hasson’s entry technique or Palmer’s point entry should be planned.

In the examination I will look for her BMI. Either extreme of BMI will make the operation complicated. I will examined her abdomen for any scars. If her BMI is high or very low and any scar on her abdomen the procedure should be done by senior person or by the consultant.

In the counselling I will tell her that laparoscopic sterilisation is a permanent method of contraception and it will be not reversed in NHS. Because it is an operative procedure it has anaesthetist and operative complications.
There are other reliable methods of contraception available, some of the method has almost has equal pearl index and some of them has much smaller pearl index then female sterilisation. The other important aspect is these methods are reversible. Among the long term reversible contraceptives Cu T 380 is a intra uterine device which can be kept for 8 years, Mirina IUS has Levenogestral. This device releases 20 mig hormone daily in the uterus. Systemic side effects are minimum. This will reduce the menstrual loss by 90 % and around 30 % of them will have amenorrhoea in 8 to 9 months time. If the patient has menorragia this will be a good option for her. Implanon implant , this is a small rod shape device can be inserted sub dermally. Which can be changed in three years. Depoprovera is a form of an injection. 150 mg intra muscular injection last for 12 weeks. This causes irregular bleeding initially later amenorrhoea is the norm.
If not contraindicated combined oral contraceptive is other option. Periods will be regular and bleeding will be minimum. If the patient has pre menstrual symptoms which can be treated with this. Similarly progestogen only pill can be used where combined oral contraceptive pills are contraindicated.
The other option is her partner can go for vasectomy. It is a minor surgical procedure, where general anaesthesia is not necessary. It is done under local analgesia. Failure rate is 1:2000 where as laparoscopy sterilisation the failure rate would be 1:200. Top of this, in case following laparoscopic sterilisation if she become pregnant possibility of ectopic pregnancy is high. Ectopic pregnancy has high morbidity and mortality.
In practice most of the mothers who gone for laparoscopic sterilisation has expressed their regret.
I will give written information and ask her think about it and make a final decision.

(b)
I will verify the patient’s name, address and date of birth before proceeding with the consent. I will explain about the procedure to her in detail. Also mention possible alternate methods which were discuss during counselling.
The benefit of undergoing this procedure is it is a permanent method. No need to worry about the compliance. Advers effects of the contraceptive medication can be avoided.
The serious risks are failure of the procedure is around 1 in 200. Laparoscopy surgery has risk of 0.4/1000 bowel injury, 0.2/100 bladder injury and 0.1/1000 great vessel injury.
Following injury if bleeding occurs may require laparotomy and blood transfusion. Other specialities will be involved ie bowel surgeon or vascular surgeon.
If any difficulties occurs while doing laparoscopy it will be converted in to laparotomy.

(c)
I will ask the patient if she has any further question regarding the procedure and I will answer her. I will document her last menstrual period, contraceptive history. If she is on any pill I will ask her to continue until it finishes. If she is not on contraceptives I will ask her to use some form of contraceptive for another seven days .Her Hb% needs reviewing. I will ask my staff to perform urine pregnancy test to excluder pregnancy. I will explained to her thought pregnancy test is negative still there is a possibility of having luteal phase pregnancy if she would have had unprotected sexual intercourse recently.
If the consent was singed some times ago, I will go through it again and counter sign the consent form and give the copy to her.

Posted by SANCHU R.
A healthy 28 year old mother of 2 children has been referred because she requests laparoscopic sterilisation. She had two vaginal deliveries. (a) Discuss your assessment and counselling of this woman [10 marks].
She is informed that sterilisation is a permanent procedure. Although reversal can be done, the success rate is only 50-60%. IVF carries a success rate of only 25%.
There is a chance of regret after the procedure.
She must be informed about the various methods of Long-acting Reversible Contraception available including DMPA, IUD, LNG-IUS, Implanon and the benefits and risks involved.
She must be informed that vasectomy is an option which is safer and has a lower failure rate.
Her assessment would include BMI, enquiring about any operations in the past- since laparoscopy should be done with necessary precautions. The date of her last delivery is noted since laparoscopy is advisable only after 6 weeks of last child birth. Her menstrual history and her present contraception are noted. If she is using IUD or Mirena, barrier or abstinence is advised for 7 days before operation. Information leaflets are provided.
(b) Outline the information that you will discuss with the woman in order to obtain informed consent for laparoscopic sterilisation [6 marks].
The operation should be explained in easily understandable language -that the fallopian tube is blocked or cut..
She is informed that the benefit of the operation is preventing pregnancy.
She must be informed that there is a failure rate of 1 in 200. If there is a failure, there is a high risk that it may be an ectopic pregnancy. The serious risks are injury to blood vessels, bowel or bladder -a risk of 3 in 1000, and there would be need for laparotomy and/or Blood transfusion if such injury occurs.
There is risk of hernia .
The risk of death related to laparoscopy would be 1 in 12000
The frequent risks would be shoulder tip pain, bruising and infection.
(c) She is listed for laparoscopic sterilisation and attends as a day case. Discuss your pre-operative assessment [4 marks].
Her LMP is noted. If she is in luteal phase and not on effective contraception, She should bear the responsibility if she is already pregnant. Her decision is again checked and chance of irreversibility and regret repeated. She is explained that she may go home the same day when she will be eating, drinking, passing urine and free from the effects of anaesthesia.
Posted by Johnson  O.
A/
I will take a detailed menstrual history. Her last menstrual period, to exclude pregnancy. Menstrual cycle, if regular or irregular. menorrhagia. Contraceptive history, both past and present form of contraception are they effective and why she want sterilization. Any gyneacological symptoms like dysmenorrhea, dyspareunia or chronic pelvic pain, because sterilization will not improve the symtpoms. I will use the opportunity to ask about her last cervical smear test and the result. Any previous abdominal surgery like laparatomy.
Examination will include her BMI. Abdominal examination for any mass to exclude pregnancy.
I will explain to her that sterilization is intended to be a permanent procedure. Reversal may be difficult, expensive and NHS may not fund it. The failure rate is 1 in 200woman. If it fails there is risk of ectopic pregnancy which is 1 in 20. I will explain to her other form of contraception which are equally effective. Mirena coil is 99.5% effective, it can last for 5years and can also reduce menstrual blood loss.Implanon given under the skin and can last for 3years. Depot medroxyprogesterone is IM injection giving every 3months and very effective. Oral pills in form of progestogen alone or combined pills. If she is in a stable relationship her partner can have vasectomy with failure rate of 1 in 2000 procedure.
She needs to continue her present form of contraception until the menstrual period after the sterilization. The procedure will not alter her menstrual cycle and it will not protect against sexually transmitted infection.
I will provide her with information leaflet about various form of contraceptions and sterilization. Clear documentation of the discussion.
B/
I will tell her that the procedure is called Laparascopy sterilization. It involve key hole surgery through the abdominal wall. The two fallopian tubes will be blocked using Fischi clips.
The procedure will be done under anaesthesia, either general or regional.
The frequent risks include pain in the wound and abdomen, wound infection or failure to gain entry to abdomen. Serious complication include Injury to major vessels causing excessive bleeding. Injury to abdominal and pelvic organs, most especially bladder, bowel with risk of proceeding to laparatomy. There is also risk of hernia formation.
Additional procedure will include blood transfusion in case of excessive blood loss and repair of any injury. I will ask her of any procedure she will not consented to like refusal of blood transfusion.
Alternative to the procedure include laparatomy sterilization which involve wide abdominal incision. Hysteroscopy sterilization, but not widely available. Other forms of contraception
I will give her information leaflet about laparascopic sterilization.
C/
I will ask her about her last menstrual period and if she think she may be pregnant. It is important to avoid the procedure in lutea phase. I will ask her if she still want to go ahead with the procedure. Abdominal palpation to exclude any pelvic mass or pregnancy. Urinary pregnacy test will be performed, having in mind that it may be negative in lutea phase pregnancy.
Posted by Mohamed A.
a)
Asking about no of pregnancies, mode of deliveries as repeated c.sections carries an increased risk of adhesions, date and outcome of last pregnancy, tubal ligation performed shortly after delivery or TOP is associated with regret and higher failure rates. Enquiring about her menstrual cycle length, and regularity as women with meorrhagia and irregular cycles alternatives as Mirena may be considered. Date of her LMP to exclude pregnancy. Ask if she is currently using contraceptives and previous contraceptive history and why do she requests sterilization, failure of previous contraception and unawareness of alternatives may be the only reason for her request. History of PID or significant pelvic pathology eg endometriosis may make options like LNG-IUS more appropriate.
Enquire about previous abdominal surgeries. Assess her BMI and check abdomen for scars of previous laparotomies. Ask about the stability of her relation ship and if she is certain that she don’t want any more children.

Although not a legal requirement it’s a good practice to involve both partners in decision making.

I will inform her that it is a permanent and irreversible method of contraception carrying a failure rate is 1:200 over life time and there is an increased risk of ectopic pregnancy if tubal ligation fails. I will discuss with her other methods of long acting contraception, Cu IUD can be used for 5-10 years, Mirena can be used for 5 years and Implanon for 3 years, all of which have a low failure rate and all are reversible. Mirena can be of benefit if she has heavy periods. Rates of successful pregnancy after reversible of sterilization is variable and carries a risk of ectopic pregnancy. Vasectomy is an alternative which carries a lower failure rate of 1:2000 over life time and with fewer risks.

I will tell her that if her cycle is controlled by hormonal contraception, irregularities may recur after tubal ligation and stopping COCPs. Tubal ligation doesn’t offer protection against STIs.

I will inform her that the procedure is performed laparoscopically and requires general anesthesia and there is a possibility of requiring laparotomy particularly if previous abdominal surgery or overweight.

She should receive written information about sterilization and alternatives.

b)

Information about the procedure, it is a day case procedure performed under GA, using laparoscopy or mini-laparotomy applying Filchie clips to occlude the tubal lumen but other methods might be used such as cutting the tube and suturing both ends or the use of diathermy may be required.

Serious risks associated with laparoscopy include bowel, bladder and vessel injuries and failure to gain entry into the abdomen. She should be informed that laparotomy may be resorted to in case of visceral injury or failure to gain entry into the abdomen and blood transfusion may be required, and other specialities may be involved. Frequent risks of laparoscopy include abdominal discomfort and shoulder tip pain.

She should be made aware of the significance of post-operative symptoms such as abdominal pain and feeling generally unwell which may indicate unrecognised bowel injury.

Information about the surgeon, that the procedure will be performed by an appropriately trained surgeon or a trainee under supervision.

Information about the hospital such as when and where to report for admission.

Precautions she should take such as the use effective contraception until the date of the procedure and to continue until their next period

Written information should be provided to her and sufficient time allowed to read, assimilate and consider before surgery.

c)
Take a detailed menstrual history before the procedure as to avoid luteal phase sterilizations. I will ensure that the woman has used effective contraception up until the date of the procedure. Otherwise the procedure should be deferred until the follicular phase and the woman advised to use effective contraception until her next period. Negative pregnancy performed at the luteal phase test does not exclude pregnancy.
I will review consent form and that she is sure of her decision. I will ensure all equipment is tested and appropriately maintained. Abdominal should be palpated for any masses and position of aorta. Finally make sure that the right procedure is performed to the right patient.
Posted by Bee N.
A) I will ask about any previous contraception used and why patient is asking to be sterilised. I will ask fo previous history of past abdominal surgery which may increase operative risk. I will ask about drug use which may reduce the efficacy of oral hormonal contraception. I will then ask about any recent history of termination, miscarriage or delivery which further reducing efficacy of sterilisation. I will ask about her last menstrual period as she may be pregnant already and ask about history of menstrual disorders such as menorrhagia which she may need treatment for since these are not altered by sterilisation.

I will examine the patient, checking for her BMI to assess suitability for laparoscopy, examine her chest to exclude chest pathology and suitability for general aneasthesia. I will examine her anbdomen to exclude masses. I will examine her vaginally if i have any concerns about pelvis pathology such as ovarian cyst or fibroids.

Investigations wil be based on findings on physical examination. and these may include chest x ray, abdominal/ pelvic ultrasound scan, urine pregnancy test and full blood count.

I will inform this patient that due to her age, there is a higher probability she may want to change her mind in future and so may want to consider other forms of contraception not already tried. I will inform her of the implanon which is 99.99% effective and its side effect of unpredictable bleeding and reduction/ seization of periods. I will inform her of intrauterine conyraceptive devices and systems which is 99% effective. I will also inform her about the hormonal contraceptives which are taken orally or injectables, their efficay and side effects. I will inform her that vesaectomy is an alternative and has a failure rate of 1 in 2000. It is done as a day case and associated with less complications. i will inform her that laparoscopic sterilisation is done under general anaesthsia and must be considered irreversible. Reversal is difficult with a variable rate of success and increased risk of subsequent ectopic pregnancy (0-7%). She will need to inform hospital if she thinks she is pregnant of develops abnormal bleeding after sterilisation. The procedure is done as day case and failure rate only about 1 in 200. Their will be risk associated with it which will include anaesthetic, perforation of bowel, bladder/ureter, bleeding and infection. It will not change her periods and does not protect her from sexually transmitted infections. She will need to start effective contraception till she is sterilised and after sterilisation until her first period. i will offer her an information leaflet if available, inform her she needs to make an informed choice and document all discussions. I will inform her confidentiality will be maintained, advice her to discuss the issues with her partner if not already present. Consent will be taken when patient is willing to give it.


B) Her pre op assessment will start with taking a history of adequate contraception since last visit. I will ask if she ha s developed any medical condition that may put her at anaesthetic risk such as chest infections. I will ask about her last menstrual period to assess risk of pregnancy. i will then examine her chest to detect any signs of infection and her abdomen for any abnormality. I will take blood for full blood count to ensure patient not anaemic and group and save in preparation for surgery. I will do a urine pregnancy test. I will inform anaesthetist to review patient especially if i think she may have a significant anaesthetic risk. i will take consent if not already taken. Document all findings and discussions and answer any questions she may have.
Posted by Bee N.
A) I will ask about any previous contraception used and why patient is asking to be sterilised. I will ask fo previous history of past abdominal surgery which may increase operative risk. I will ask about drug use which may reduce the efficacy of oral hormonal contraception. I will then ask about any recent history of termination, miscarriage or delivery which further reducing efficacy of sterilisation. I will ask about her last menstrual period as she may be pregnant already and ask about history of menstrual disorders such as menorrhagia which she may need treatment for since these are not altered by sterilisation.

I will examine the patient, checking for her BMI to assess suitability for laparoscopy, examine her chest to exclude chest pathology and suitability for general aneasthesia. I will examine her anbdomen to exclude masses. I will examine her vaginally if i have any concerns about pelvis pathology such as ovarian cyst or fibroids.

Investigations wil be based on findings on physical examination. and these may include chest x ray, abdominal/ pelvic ultrasound scan, urine pregnancy test and full blood count.

I will inform this patient that due to her age, there is a higher probability she may want to change her mind in future and so may want to consider other forms of contraception not already tried. I will inform her of the implanon which is 99.99% effective and its side effect of unpredictable bleeding and reduction/ seization of periods. I will inform her of intrauterine conyraceptive devices and systems which is 99% effective. I will also inform her about the hormonal contraceptives which are taken orally or injectables, their efficay and side effects. I will inform her that vesaectomy is an alternative and has a failure rate of 1 in 2000. It is done as a day case and associated with less complications. i will inform her that laparoscopic sterilisation is done under general anaesthsia and must be considered irreversible. Reversal is difficult with a variable rate of success and increased risk of subsequent ectopic pregnancy (0-7%). She will need to inform hospital if she thinks she is pregnant of develops abnormal bleeding after sterilisation. The procedure is done as day case and failure rate only about 1 in 200. Their will be risk associated with it which will include anaesthetic, perforation of bowel, bladder/ureter, bleeding and infection. It will not change her periods and does not protect her from sexually transmitted infections. She will need to start effective contraception till she is sterilised and after sterilisation until her first period. I will offer her an information leaflet if available, inform her she needs to make an informed choice and document all discussions. I will inform her confidentiality will be maintained, advice her to discuss the issues with her partner if not already present. Consent will be taken when patient is willing to give it.

B) To obtain an informed consent I will discuss the procedure which is under general anaesthetic and how it will be done mostly as a day case. I will discuss the benefits which will include effective contraception(failure rate 1 in 200). I will discuss the risks which include aneasthetic, damage to bowel and bladder (less than 10 in 1000), infection and bleeding.I will discuss draw backs which include noj protection from sexually transmitted infections and not altering peroid cycles. I will discuss alternative contraception which will include vasectomy (1 in 2000 failure rate)


C) Her pre op assessment will start with taking a history of adequate contraception since last visit. I will ask if she ha s developed any medical condition that may put her at anaesthetic risk such as chest infections. I will ask about her last menstrual period to assess risk of pregnancy. i will then examine her chest to detect any signs of infection and her abdomen for any abnormality. I will take blood for full blood count to ensure patient not anaemic and group and save in preparation for surgery. I will do a urine pregnancy test. I will inform anaesthetist to review patient especially if i think she may have a significant anaesthetic risk. i will take consent if not already taken. Document all findings and discussions and answer any questions she may have.
Posted by Leen K.
LEEN
A healthy 28 year old mother of 2 children has been referred because she requests laparoscopic sterilisation. She had two vaginal deliveries. (a) Discuss your assessment and counselling of this woman [10 marks].

I would explain what laparoscopic sterilisation entails and explain that it is a permanent form of contraception which is non-reversible under NHS funding. I would make sure that she is certain that her family is complete.

I would enquire about her menstrual history (last menstrual period, regularity, cycle length, and menstrual problems such as dysmenorrhoea and menorrhagia) and I would make sure she does not have any undiagnosed vaginal bleeding. I would find out about her previous and current contraception, as well as any problems she has had with them, as well as contraindications to certain contraceptives (eg. focal migraine with combined oral contraceptives). I would enquire about any previous surgery and history of pelvic infections that may complicate laparoscopic sterilisation.


I would counsel her that there tends to be higher regret rates in women under 30 years old having laparoscopic sterilisation. I would explain that there is a failure rate of 1:200 over a lifetime associated with female sterilisation. I would also discuss operative and anaesthetic risks associated with the procedure. I would also inform her that her menstrual loss may increase following discontinuation of her hormonal contraception (as these tend to have a positive effect of reducing menstrual loss). I would also counsel her about the increased risk of ectopic pregnancy if she does fall pregnant following laparoscopic sterilisation; therefore she needs to perform a pregnancy test if she misses a period and attend for early scan if is is indeed pregnant (to confirm intrauterine pregnancy).

I would also discuss other options for long acting contraceptions such as Depoprovera injections (3 monthsly injections), Implanon (lasts 3 years) and Mirena coil (lasts 5 years, and failure rate of 1:1000). I will explain that these have the advantage of being inserted in an outpatient setting (+/- local anaesthetic) and avoids the risks associated with an operation. I would also discuss vasectomy - with its failure rate of 1:2000, and the fact that it is usually done under local anaesthetic (thus avoiding operative and general anaesthetic risks).

I would counsel her that she needs to use reliable contraception until the menstrual period after her laparoscopic sterilisation, if she is certain she wants to proceed with the sterilisation.





(b) Outline the information that you will discuss with the woman in order to obtain informed consent for laparoscopic sterilisation [6 marks].

I would explain that laparoscopic sterilisation is the name of the procedure and that it involves occluding her fallopian tubes to try to prevent pregnancies from occuring, and is normally done under general anaesthetic & Filshie clips are usually used for tubal occlusion. It is a laparoscopic precedure (key-hole/minimal access surgery) and is associated with general anaesthetic risks; risk of injury (approximately 1:1000 - 1: 2000) to visceral organs (eg bowel, bladder, urinary tract) and vessels; pain postoperatively (abdominal cramping, shoulder tip pain); and a failure rate of 1:200. I would explain that if complications are encountered, there is a risk of the operation being abandoned, and a risk of laparotomy (to examine and/or repair injury if required, or to complete the sterilisation).

I would discuss the options (including benefits and risks) of other contraceptives such as Mirena coil, Implanon and vasectomy; and the option of no treatment. I would explain what procedures will not be done (eg. oophorectomy); and I would give her an information leaflet of laparoscopic sterilisation. I would also give her a contact telephone number for the department in case she has any further questions or concerns.


(c) She is listed for laparoscopic sterilisation and attends as a day case. Discuss your pre-operative assessment [4 marks].

I would examine her chest and heart sounds to ensure there is no undiagnosed murmurs or chest infection that may complicate her operation. I would check her blood pressure to make sure she has no undiagnosed hypertension. I would ask her about her last menstrual period; whether she has been using reliable contraception, as well as perform a pregnancy test - the procedure should ideally be done during the first half of the menstrual cycle to reduce the risk of failure due to pre-existing early pregnancy. I would confirm that she still wishes to proceed with the procedure.
Posted by M E.
ME
a) Discuss your assessment and counselling of this woman [10)
I would enquire about the date if her last menstrual period and frequency of her menses, to help rule out a current pregnancy. I would also ask about problems associated with her menses such as mennorhagia, dysmennorrhea, since other methods of contaception such as the Mirena can also be used to treat these problems.
I would ask about previous contraceptive methods that she may have tried, any side effects that she may have encountered and reasons for not wanting to try other methods. I would counsel her and her partner if presents about possible alternatives such as vasectomy, which can be carried out under local anaesthesia, less complications associated with it and lower failure rate of 1:2000 as compared to 1:200 with tubal ligation.
I would ask about her history of previous STD or PID, since these may require treatment or may increase her risk of adhesions. I will also enquire about other conditions that may increase intra abdominal adhesions such as previous surgery, ruptured ectopic, endometrisis. She should be counselled that these risk factors may make her surgery more complicated. Date of her last papsmear and findings.
I would enquire about the number of pregnancies that she has had and their outcomes, such as ectopic and miscarriages. Age of her last child, complications associated with her previous pregnacies such as pre eclampsia. I will also enquire whether the vaginal deliveries that she had resulted in live births and whether they are alive and healthy currently.
I will also enquire about her medical health. If she has any conditions that would prevent her from having general anaethesia.
On examination i will calculate her BMI. Since underweight and obese patients make laparoscopy more difficult. I would check for any abdominal masses, scars, hernias, that would make surgery and access difficult.
I will counsel her that tubal ligation is irreversible and ensure that this is the form of contaception that she wants. Also there is still a 1:200 chance of getting preganant and there is a higher risk of ectopic pregnancies. She should be counselled on other types of contraception that have similar success rates such as implanon and intrauterine contaceptive devices such as Mirena.
She will be given an information leaflet about laparoscopic tubal ligation and advised to read it before making her final decision

b)Outline the information that you will discuss with the woman in order to obtain informed consent for laparoscopic sterilisation [6

Explain to her that the procedure involves two small cuts, one at the navel and the other lower on the abdomen. This would allow a camera and instruments for the procedure to be inserted. Clips will be placed on the fallopian tube or electordiatermy can be used to block the tubes. General anaesthesia will be required to perform the procedure. Will be a day case and patinet will require admission on the day of surgery and will be discharged after the procedure once stable.
The benefits of the surgery would be the prevention of future pregnancies. However there are serious but less frequently encountered risks that can occur. Injury to bowel 0.4/1000 , injury to vessels or bladder 0.2/1000. If these injuries do occur there is the need for further intervention, such as laparotomy and visceral repair. There may be problems gaining access to the abdomen and an alternative route or mathod may have to be used. More frequent complications that occur include bruising and shouldertip pain.
Explain to the patient that the risks of the surgery are greater if there was previous surgery or raised BMI.
Alternatives to the surgery should be discussed, these include vastectomy, long acting reversible contraception IUCD, implant or no treatment.

c)She is listed for laparoscopic sterilisation and attends as a day case. Discuss your pre-operative assessment [4 marks].
Ensure that she understands the procedure to be performed and she still wants the surgery.
Check when her last LMP was and perform a UPT, to ensure that sheis not pregnant at the time of the procedure.
If she has any medical conditions, such as angina or HTN ensure that she is reviewed by the anaesthetist.
Perform preoperative bloods such as CBC.
Ensure that she remains NPO prior to the procedure.
Obtain informed consent from the patient preferably by the surgeon for the case. Answer any questions that she may have relating to her surgery.
Posted by A H.
AH
a)A detailed menstrual history will be taken. This includes the date of her last period as well as its regularity. I will also ask about post-coital bleeding, dysmenorrhoea and deep dyspareunia which may indicate pelvic pathology.
History of contraception use and any failure of the method will be asked. I will enquire in a sensitive manner if there are any psychosexual issues which may influence this request.
A history of, and indication for, any abdominal surgery will be taken.
Her BMI will be calculated.
An abdominal examination will be done to assess for abdominal wall fat, masses and surgical scars.
A pelvic examination will be done to identify cervical pathology, and to assess the size and mobility of the uterus and any adnexal masses or tenderness.
She will be advised that sterilisation is intended to provide permanent contraception. I will tell her that the procedure can be
reversed but this service is not provided by the NHS. Success of reversal is between 31 to 92% depending on the method of occlusion. Her lifetime risk of falling pregnant after sterilisation is 1 in 200, and if pregnancy occurs it is likely to be in the tubes.
She will be advised that long acting reversible contraception in the form of implants and intrauterine devices (copper or LNG-IUS) is available. The failure rate of each method will be given. The LNG-IUS can also provide relief with menorrhagia.
Another option available is for her partner to have a vasectomy which is associated with a much lower failure rate of 1 in 2000, and it is associated with a lower complication rate.
She will be advised that it is necessary for her to continue to use reliable contraception until her first period after the procedure.
She will be given written information and documentation of information given will be made in the notes. She will be given another appointment to discuss any concerns which she may have.

b) I will tell her that the name of the procedure is laparoscopic sterilisation, which will be done as a day case and she will be discharged the same day.
The fallopian ubes will be occluded by placing a Filshie clip across each tube thereby occluding the lumen and preventing the sperm from reaching the egg for fertilisation.
Access to the tube will be gained by placing a small incision just below the umbilicus and another above the hairline. A telescope is placed in the abdomen through the infraumbilical incision and callipers are placed through the other incision. The tubes are grasped under direct vision and the clip placed across each tube.
She will require general anaesthetic.
Serious risks include failure of the procedure of 1 in 200 resulting in a pregnancy which will most likely be located in the tube. Also it may not be possible to gain entry into the abdomen. There is a risk of injury to bowel, bladder or major blood vessels. This risk is estimated as 3 in 1000 procedures and if it occurs a laparotomy will be necessary for repair of the injury. Consequently she will be kept in hospital for a few more days.
Frequent risks are bruising and shoulder tip pain. The risk of death is very small; about 1 in12000 women.
She will be reminded of alternative contraception in the form of long acting reversible contraception. A statement of any procedure which she does not want to have done ,will be taken

c) Pre-operative assessment include taking a history of any acute illness,for example upper respiratory tract infecion which may be a containdication to general anaesthesia.
The date of her last period will be taken. Any irregular bleeding will be noted. The history of contraception use since her last period will be taken.
A pregnancy test will be done.
If there is the possibility of inadequate contraception, she may be pregnant with a luteal phase pregnancy even though the pregnancy test may be negative. She would thus be advised to defer the procedure until the follicular phase of the next cycle if there is space on that list. or on the next available list. .
Posted by robina K.
(A) I will asses her mental capacity and explore reasons for sterilisation at such a young age .I will take her obstetric history, parity, age of the youngest child as immediate post natal sterilisation carries greater risk , mode of deliveries, wheather vaginal or casearean section and lactation .I will ask about her menstrual cycle regularity , amount of bleeding and LMP. I will ensure there is no other gynecological condition for which some other procedures are needed like menorrhagia or fibroids ..Any contraception she is using and the type of contraception, IUCD, COCPs, POPs, implants or depots. Previous abdominal surgery is inquired about . I will inquire about comorbidities like diabetes, hypertention . I will ask about her social history and partner/husbands support . I will check her B.P and BMI .
Councelling includes providing informations about sterilisation intended to be a permanent procedure, can be performed laparoscopically using filshie clips routinely, via mini laparotomy ,ligating and cutting a part of tube . Performed as a day case under regional or general anesthesia or rarely local anesthesia .Procedure related serious risks like failure to gain entry, bowel, bladder and vascular injury , and need for laparotomy should be discussed . Frequent risks like abdominal discomfirt and shoulder tip pain . Failure rate is 1 in 200 with an increased risk of ectopic pregnancy .Reversal is possible depending on the availability of expertise but may not be available at NHS. Succes rate varies and could be arround 60% with an ectopic pregnancy rate of 4-7% .I will councell the women about the alternatives like male sterilisation, IUCDs, implants. I will provide her with written information and documentation of all counselling.
(B) Previous abdominal surgery , carries risk of bowel injury which may need laparotomy in 2 in 1000 and bowel repair or temporary colostomy . Risk of death is 1 in 12000 .
Failure rate is 1 in 200 with a risk of ectopic pregnancy could be 0-7%. Risk of under lying pregnancy as negative pregnancy test does not excude pregnancy ,therefore she is advised to use effective contraception before and after sterilisation till her next periods . I wil discuss the alternative procedures there advantages and disavantages.
(C) I will ensure she is certain of her decision and she is aware of the procedure which she is undergoing and the type of anesthesia she will be recieving .I will inquire about the informations provided to her including written regarding the procedure .I will ask about her LMP and confirm she is using contraceptives otherwise the procedure should be delayed .I will check her investigations like FBC, group and antibodies and pregnancy test . I will check she has signed a proper consent form . I will check her B.P .
Posted by Manoj M.
M
(a) A history should include that she is definitely completed her family and and she is under no coersion or undue pressure in her decision making. A detailed menstrual history including her LMP to exclude underlying pregnancy and her current and past method of contraception as helpful in her counselling.
Examination should include Blood pressure and BMI as a part of pre-opassessment and if suspicious of pregnancy exclude with urine pregnancy testing.
Her counselling should be nondirective by a Gynaecologist. She should be explained that it is intended as a permanent sterilisation method and she may not be funded if she needs a reversal under NHS. Also the success may vary with such reversal and if she need IVF or ICSI she may not be funded for this in the NHS. With her age being 28 sterilisation is associated with higher rates of regret in future and she should be offered counselling sessions. Sterilisation will not change her menstrual cycle and if associated with heavy menstrual bleeding she may need other form of treatment with contraceptive efficacy as an alternative to sterilisation. Sterilisation is associated with risk of surgical and anaesthetic complications and she may avoid this by using alternative methods.

(b)Name of the procedure is laparoscopic tubal sterilisation which involves blocking both fallopian tubes and intended benefit is permanent tubal sterilisation.
Procedure related serious injuries involves faliure rate of 1 in 200 with increased risk of ectopic pregnancy with failure. Risk of bowel, bladder and vesse injury 3 in 1000, Risk of death with procedure 1 in 12,000, Risk of failure to entry and uterine perforation. Frequent risk involves shoulder tip pain and bruising of abdominal skin at operation site.
Anaethesia is usually under general anaethesia and assoictaed wih its own risks.
Alternative procedures include Hysteroscopic sterilisation but not available in all centres, alternative contraceptive options includes vasectomy with failure rate of 1 in 2000, IUCD/IUS, Implanon, Depot preparations, Oral contraceptives and these will be explained with failure rates and side effect profiles.
Additional procedure required may be laparotomy to complete tubal occlusion or to treat visceral injuries. Any objection for blood and blood products should be documented.
Patients wishes and other procedure done at same time should be documented. She will be provided with written information and leaflets.

(c) Her informed consent should be checked as complete and any further questions answered and any objection documented, proceed only if no change in her plans.
Check recent full blood count to ensure she is not anaemic and a validated group and save available prior to the procedure. Ensure her general health has not changes from the previous consultation and no further anaesthetic risks.
Exclude any possibility of pregnancy from history and if in doubt postpone procedure. HCG testing may suggest non pregnanct but will not identify luteal phase pregnancy.
Advice her to continue the current method of contraception untill her next periods and if she needs a current contraceptive coil removal ensure no unprotected intercourse in the last 7 days, if not defer removal after next periods.
Posted by SUNDAY A.
sos\' answers

I would enquire about her general well being including her LMP and menstrual periods and related symptoms including mennorrhagia, intermentrual bleeeding, dysmenorrhea which may be related or unrelated to her request. Present contraception- if sexually active and currrent partner and past history of STI/ PID and treatment received and cervical smears may give an insight to her reason for the request. Past gynaecology history including surgery which may directly affect the complexity of the procedure should be asked. Revevant social history including the age and well being of her children, occupation, smoking and alcohol ingestion is also relevant. Present medication and drug allergies should be confirmed as well. I would check her BP, BMI( should ideally be below 30) and abdominal examination to check for any scars, mass or tenderness may be sufficient. Routine blood including FBC and Group and save is sufficient for her intended procedure.
I would inform her if she is very sure sure of her decision and well thought through with the support of her partner. I would inform her of the other methods such as combined/ mini-pills, LARCs including Depot injection, Implanon, Copper IUD, Mirena IUS or vasectomy (if in a relationship). I would tell her that Sterilisation is irreversible contraception and permanent and reversal not funded under NHS with limited success.I would also tell her of the risk associated with laproscopic sterilisation and give her information leaflets adding a note that the procedure has no effect on her periods. If she is adamant and seems very sure and able to consent in the clinic, i would inform my consultant ( in view of her age) about the request and if my consultant is happy i would list her.
b) The information would involve explaining the nature of the procedure in clear terms and the benefit of the procedure which is to prevent future pregnancy. I would tell of the common risk which would include shoulder tip pain, abdominal discomfort infection, failure of the procedure-1 in 200, risk of ectopic pregnancy, anaesthetic risk and major complication would include bowel perforation ( 0.4%), injury to vessels (1 in 1000) and bladder injury which may necessitated conversion to laparotomy to repair the visceral damage or if unable to gain entry into the peritoneal cavity. Blood transfusion may also be required.
c)Pre-operative assessment would involve excluding pregnancy by doing a urinary prenancy test, checking her observation including BP, Temperture, Pulse rate. Any doubts about the operation should be confirmed and consent checked and confirmed by the surgeon. Blood results should be checked and acted upon and any other problems should be anticipated and prevented.
Posted by Nur Sakina K.
NSK

From A:
History re contraception-both current and previous methods must be addressed. Any side effects, compliance issues, difficulties and failed methods must be asked. A menstrual history re regularity of cycle, presence of menorrhagia or irregular bleeding should also be elicited. It should be explained that there are limited data re effects of sterilization on menses in woman before 30 year old. Her parity, timing of last delivery and certainty of wanting sterilization must be assessed to avoid future regrets and the failure rate is higher if done soon after a pregnancy. Past surgical history of abdominal procedures, specifically laparotomies is important as may cause difficulties during laparoscopic entry.
Examination involves obtaining her weight and height to measure BMI as entry may be more difficult if she were obese.

The procedure intended is a laparoscopic tubal occlusion using Filshie clips which is done under general anesthetics. It is usually performed as a day case, which will allow her to be discharged that evening. I’d explain that this is the currently recommended method of laparoscopic sterilization, although other techniques may be available such as hysteroscopic occlusion which is still under evaluation. If this procedure were to fail which occurs in 1/200 cases, there is a risk of ectopic pregnancy occurring. Therefore, I’d advise her to present to hospital if she thinks she may be pregnant or has any abnormal bleeding/pain to exclude this. I’d explain that this is a permanent and irreversible procedure where she must be certain of wanting it. If reversal was requested, the success rate of a subsequent intrauterine pregnancy varies, but maybe up to 90%, with an ectopic rate of up to 7%. It should be explained that this procedure is not funded by the NHS. Risks associated with the procedure are also addressed. There may be minor complication such as abdominal pain, nausea, vomiting, and shoulder tip pain which are common and transient in up to 3% cases. To reduce post op pain, local anesthetic will be applied to the tubes. Major risks such as visceral and vascular injury, uterine perforation and failure to gain entry into the abdomen requiring a mini laparotomy must also be disclosed. If these complications were to occur, there is a 3/1000 risk that a laparotomy will be needed. Alternative methods of contraception such as long acting reversible contraception (Mirena-IUS, Depo-Provera and Implanon) has a high success rate with added advantage of treating any menstrual problems such as menorrhagia, irregular bleeding. Vasectomy should also be discussed which is associated with a lower failure rate (1/2000) and morbidity compared to tubal occlusion. The counseling should be properly documented in the notes and written information leaflets are given to support this.

Fr B:
I’d explain the procedure intended is a laparoscopic tubal occlusion using Filshie clips. It will be performed as a day case and under general anesthetics. I’d explain that it is a permanent procedure and irreversible procedure, which can fail in 1/200 cases. If this were to occur, there is a risk of ectopic pregnancies. I’d also explain the risks associated with it such as abdominal pain, nausea, vomiting, and shoulder tip pain which are common and transient in up to 3% cases. Major risks such as visceral and vascular injury, uterine perforation and failure to gain entry into the abdomen requiring a mini laparotomy must also be disclosed. If these complications were to occur, there is a 3/1000 risk that a laparotomy will be needed. I’d ask if she had any further questions before signing the consent.

Fr C:
I’d enquire re any co-morbid conditions that may require additional procedures/precautions to be taken. A gynae history of menorrhagia or other significant pelvic pathology must be addressed as she may be more suitable for an intrauterine contraceptive device (Mirena) or hysterectomy. I’d also ensure that effective contraceptive has been used up to the day of surgery and she should continue this til her next period. If this has not been done, I’d defer the surgery til the next follicular phase and advise using contraception til then. This is to ensure that no pregnancy has occurred prior to sterilization.
A urine pregnancy test to exclude pregnancy is done. However it should be explained that a negative test does not exclude a luteal phase pregnancy and that routine curettage to prevent this is not done intraoperatively.
Posted by Maayka ..
maayka

a) A history from the patient with respect to her present and previous use of contraceptive methods will determine her reason for laparoscopic sterilization (lap. steri) – like if she had any failures while on those methods, were there any side effects she may want to avoid like withdrawal bleeding and progestogenic effects with the combined pill. Any previous surgeries like Caesarean sections, herniorraphy and the incision type will determine the likelihood of adhesions present, which will make laparoscopic entry difficult. Any use of drugs and allergies and history of smoking is of relevance to the effectiveness of general anesthesia. She would be advised to stop smoking at least 3 days prior to the operation date. Any gynaecological problems like menorrhagia, dysmenorrhoea, other menstrual irregularity may warrant further investigation before the surgery – as it is likely that another form of contraception e.g. Mirena coil may be more beneficial to decrease menorrhagia as well as its contraceptive benefits.
Examination will determine her body mass index, as very obese or underweight patients are more at risk of complications from the operation. Abdominal examination will rule out any palpable masses, check for surgical scars and their location and umbilical hernias.
The patient will be counseled about the other alternative forms of contraceptive methods, especially the long acting reversible contraceptives (LARCs) available such as Mirena coil, injectable Progestogens, Implanon, as they offer approx. the same effectiveness as sterilization. She will be told that her partner can be offered a vasectomy which is less invasive, can be done under local anaesthesia, less failure rate of 1 in 2000 and less risks than lap. steri. Once it is agreed that the procedure is still requested, she will be informed of the nature of the procedure – tubal occlusion using video magnification through 2 small incisions in her abdomen. The failure rate is 1 in 200 although the procedure should be considered to be intended for permanent sterilization. General anesthesia is to be used on the day. She will be advised to continue her present contraceptive method till the next period after surgery. Written information leaflets will be provided.


b) The patient must understand that the intended benefit is permanent sterilization and must be aware of the failure rate of 1 in 200.Iif pregnancy does arise she may be at risk of an ectopic pregnancy and so should seek urgent medical attention. The common side effects are bruising on the abdomen from the incisions and shoulder tip pain from the gas which is used in the abdomen. The serious but infrequent risks include uterine perforation, injury to bowel / bladder and blood vessels, the incidence of about 3 in 1000. There is a possibility of laparotomy being performed, that is if these risks occurs, to repair the damage or because of failure to gain entry into the abdomen. The information will be provided in the written leaflets as well.


c) Pre- operatively, the patient must have the consent form rechecked and ensure she is ware of the procedure she is having and the implications. She must have been kept nil per orally for 6 hours prior and should have stopped smoking 3 days before. A full blood count will be sent off to ensure her Hb is okay and a urine pregnancy test will be done to rule out a pregnancy.
Posted by S M.
A healthy 28 year old mother of 2 children has been referred because she requests laparoscopic sterilisation. She had two vaginal deliveries. (a) Discuss your assessment and counselling of this woman [10 marks]. (b) Outline the information that you will discuss with the woman in order to obtain informed consent for laparoscopic sterilisation [6 marks]. (c) She is listed for laparoscopic sterilisation and attends as a day case. Discuss your pre-operative assessment [4 marks].

SM
a) The first step in the assessment is to take a history and to find out why she wants a laparoscopic sterilisation. Her current method of contraception, whether she is currently sexually active and the date of the at last menstrual period to determine whether she may be pregnant. The presence of medical disorders is important since these may need to be assessed to ensure her suitability for an anaesthetic and surgery. A past history of surgical procedures such as laparotomy, or a gynaecology history of conditions such as endometriosis, are important because of the increased risk of adhesions and difficulty that may be encountered at the laparoscopic sterilisation. The next step in the assessment is the examination. The blood pressure, pulse, temperature and pulse should be checked. The body mass index (bmi) should be calculated since the procedure is more difficult and carries more risk in those with bmi over 30kg/m2. The abdomen should be examined to identify masses that should be investigated prior to laparoscopy.
The counselling should include education of the woman to ensure that she knows that laparoscopic sterilsiation is a permanent procedure, what it entails and the failure rate of 1 in 200 women. I would ensure that she knows of different alternative forms of contraception which she may wish to consider such as vasectomy which has a lower failure rate of 1 in 2000 men, or reversible methods such as the combined oral contraceptive pill, injectable methods, Implanon or the Mirena intrauterine systems.

b) I would explain that the laparoscopic sterilisation is considered a permanent procedure where clips are placed on the tubes to prevent pregnancy. It can only be reversed in private hospitals and the success rate is low. It would be done as a day case and as long as there were no problems and she felt well she could be discharged on the same day. A small cut will be inside the belly button and another small cut on the lower part of her abdomen. Instruments will be put through the cuts, carrying carbon dioxide to allow us to see better, a camera, and another instrument with the clips to be used for the sterilisation.

The benefit of the procedure is to prevent her conceiving. However, the failure rate of the procedure is 1 in 200 women and will most likely lead to an ectopic pregnancy which is a pregnancy in a tube which can not survive. The serious risks of the procedure also include damage to the blood vessels which can cause bleeding, damage to the bladder or bowel. If there is significant bleeding or damage to an organ, then a larger cut (laparotomy) may be needed to repair any injuries or to stop the bleeding. Frequent risks are abdominal discomfort or shoulder tip pain after the operation.

c) I would find out if she still wants to have the operation and whether she has any questions. The date of the last menstrual period, contraception use and whether sexual active is importnat since she may be pregnant. The presence of any intercurrent ilnesses or infections should be known since this may affect whether the operation is done on that day. The full blood count should be checked to rule out anaemia. A group and save sample should be available in case she bleeds and requires blood transfusion. A urine pregnancy tst should be done prior to the operation. She should use contraception for up to 2 weeks after the operation.
Posted by Ron C.
RnRn

A.
Current method of contraception and what she used in the past, as well as her preferences must be ascertained. Reason for change and why she chooses for sterilization to make sure she doesn’t have the wrong expectations regarding its benefits. Menstrual & cycle history are asked, as irregularities and/or menorrhagia well controlled on hormonal contraception may trouble her once stopping these after sterilization. History of previous pelvic inflammatory disease or surgery to assess potential for surgical complications.
Height & weight are taken to calculate BMI and inspection to assess obesity, as this would make the procedure more difficult and increase risk. Abdomen is assessed for any surgical scars of procedures done in the past.
She must be aware that the procedure is irreversible once done, and that regret afterwards is more common in those below age 30. Successful pregnancy rates after reversal are poor and reversal is not paid for by NHS. Failure rate is 1:200 life time and if so, ectopic pregnancy is more common. There are other alternatives available, which are equally or even more reliable and she must be made aware of this. This includes male sterilization, which is much safer with less complications and only failure of 1:2000 life time after azoospermia is confirmed. Other long-acting alternatives which may be suitable for her are either cupper- or mirena coil for 5 years, 3-monthly depot-provera injections or implanon for 3 years.
Part of the counseling is providing her with written info on all options.

B.
She will come in the morning as a day case and unless problems occur, will leave the hospital in the afternoon. A small incision will be made sub-umblical to allow a camera to enter the abdomen. A second small incision suprapubic will allow the instrument that places the Filshie clip on both her tubes to enter the abdomen. She must know that there is a risk for bleed or infection. During entry of the abdomen there may be accidental damage to visceral organs such as bladder, bowel or great vessels. In about 1.5-3 per 1000 cases laparotomy for assessment and/or repair is needed. Anesthesia-related complications may occur. There is a mortality of 1:12,000 cases. As mentioned on counseling, the procedure is irreversible with 1:200 failure rate and higher likelihood of ectopic pregnancy if this happens.

C.
Consent form is checked and ascertained she understands all aspects (risks) and is keen to proceed. LMP & method of contraception at present is asked for, and a urine pregnancy test is taken to make sure she is not pregnant prior to procedure. Further assessment includes blood pressure and pulse as part of standard assessment to identify previously unknown underlying problems. Bloods are taken for full blood count for baseline Hb and for group & save in case complications arise and blood transfusion would be needed.
Posted by Mohamed A.
Dearest Paul, I just dont get it, after this points...is it a good answer or not?
Posted by AFSHEEN M.
A healthy 28 year old mother of 2 children has been referred because she requests laparoscopic sterilisation. She had two vaginal deliveries. (a) Discuss your assessment and counselling of this woman [10 marks]. (b) Outline the information that you will discuss with the woman in order to obtain informed consent for laparoscopic sterilisation [6 marks]. (c) She is listed for laparoscopic sterilisation and attends as a day case. Discuss your pre-operative assessment [4 marks].

A detailed history should be undertaken including mode of delivery for both children;her last menstrual period and current method of contraception. Also, whether she has got a stable partner and preferably should be present during the consultation.Enquire about any other pelvic pathology including menstrual history ;whether regular or rregular periods or associated with heavy blood flow; any history of intermenstrual or postcoital bleeding. Specific enquiry about symptoms of endometriosis including dysmenorrhea or dysparuenia which may make mirena IUS or other contraceptive methods more appropriate.Enquire about past medical history for anesthetic fitness and any history of abdominal procedures which may complicate the laparoscopic access.General enquiry about smears and drug history should be taken. BMI should be calculated.

Detailed discussion regarding other long term contraceptive methods and risks associated with procedure should be undertaken and documented in the casenotes.Discuss about risks and benefits of contraceptive injections,implanon, copper IUT and mirena IUS. Pregnancy rates after 10 years of CuT380 is <2% and 5 years of mirena is approximately 1%.Vasectomy is associated with lower failure rate(1:2000) as compared to female sterilsiation (1:200) and lower short term complications. Information regarding the procedure being performed under general anesthesia as a day case should be discussed; however there is a small risk of having a mini/laparotomy(3:1000) depending upon woman\'s BMI and history of previous abdominal operations.Procedure is irrversible ,and reversal not currently available on NHS.Success Rates of reversal are 30-90% depending upon multiple factors.failure rate may be higher as age <30 years. Also, increased risk of ectopic pregnancy (0-7%).There may be slightly increased risk of heavy periods as age <30. Injury to bowel, bladder, pelvic organs and blood vessels relating to the laparoscopy should be discussed.


b) Detailed discussion about other long term contraceptive methods and risks of procudure should be undertaken. Discuss about availablity and suitability of injections and implants. CuIUT has a pregnnacy rate of <2% after 10 years of use. Mirena has a 1% failure rate after 5 years of usage. Vasectomy is associated with lower failure rate(1:2000) as compared to female sterilisation(1:200) and lower short term complications.Regret is more in young patients,post tOP or immediate postpartum period.

Explain the procedure; should be booked as a daycase under general anesthesia but explain small chance (3:1000)of having a mini/laparotomy depending upon patient\'s BMI and previous abdominal surgery.

Risks including injury to bowel, bladder, blood vessels and pelvic organs relating to laparoscopy should be discussed. Discuss about irreversibility of procedure and that reversal is not currently available on NHS. Success rates after reversal operations vary between 30-90% and are associated with increased risk of ectopic pregnancy. Failure may be more than 1:200 due to woman;s age being less than 30; explain risk of ectopic pregnancy is increased (0-7%) after sterilisation, if pregnancy occurs. Dicuss complications due to general anesthesia ;40% of deaths related to sterilisation procedure occur due to anesthetic problems. Advise to continue contraception at least till she has had one period after the procedure.Verbal and written information should be made available.


c) Enquire about LMP,confirmn current mode of contraception and perform a pregnancy test. Inform that a negative pregnancy test does not exclude luteal phase pregnnacy but there is no place for routine curretage for luteal phase pregnancies.Consent should be confirmed and ensure that the patient is still keen to go ahead.
Advise to continue using contraception till she has had one period after the procedure.