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MRCOG PART 2 SBAs and EMQs

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notes334
EMQ1478
SBA2084
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sterilization

sterilization Posted by Sarah S.

a)    I would enquire about her last menstrual period, as it is recommended to do the procedure during early follicular phase. History of any contraception method that she was on before will be obtained. Any past surgical history will be noted. Her past obstetric history will be explored.  Examination will be performed to check her Blood pressure, pulse rate. Abdominal and pelvic examination will also be done.

b)     The reason why she is keen for sterilization will be obtained. I will explain to her that sterilization (tubal ligation) is a permanent way of contraception. I will ascertain if she is sure to have completed her family. The success of reversibility is undermined by many factors should that be needed, and it won’t be covered under NHS. Failure rate of  tubal ligation is 1:200. If it fails, high likelihood of ectopic pregnancy and need for early medical advice will be explained if misses her period.  Alternatives will be informed to the couple like vasectomy to her male partner as it has lower failure rate(1:2000) and less risk related procedures. Other alternatives of long acting reversible method of contraception like LNG-IUS, subdermal implanon  will be explained with their benefits and risks.  I will assure her that if tubal ligation is done, it has no effect on menstrual regularity. The risk related to the procedure and anesthesia will be explained. Information leaflet will be given and additional counseling session may be arranged if needed.

c)     Adequately trained and experienced operator is needed as part of minimizing the laparoscopic complications.  Well-maintained equipment and theatre staff is also to known  to reduce the risk during laparoscopy. Patient selection is also important. Identification for high risk factors for visceral injury like previous abdominal or pelvic surgery, PID or endometriosis is needed. If patient is at high risk for visceral injury palmer’s point may be used as entry of primary port after excluding splenomegaly  to reduce the risk of visceral injury. The inferior and superior epigastric vessels should be identified prior to secondary trocars in the lower abdomen.  Veress  needle should be checked for sharpness, spring action and patency, to allow free flow of gas. (eg saline aspiration) to confirm the intra peritoneal position of veress should be performed.  The veress needle and trocar should be inserted in thin patient while lying on flat and not in trendelenburg position  to reduce the risk of vessel injury. For adequate distension of abdominal cavity,CO2  should be insufflated to 25mmhg until trocar is inserted and lowerd to 12-15mmhg after insertion.