How long after non complicated vaginal birth is it safe to perform an open tubal ligation?

[Sleeplessbordernights]

I currently work in a high volumen OB/GYN hospital. Today OB filed a complaint against one of our attendings because he will only do a tubal ligation 6 hours after birth. I usually have them wait 30 min after birth just to make sure there’s no bleeding or any funny bussiness (this is a teaching hospital After all).

I took a deep on this topic but I didn’t find anything conclusive, what’s you take on this?

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[caligas]

Whenever they want as long as they aren’t bleeding.

 

[dabears505]

Why the rush? So they can use the epidural?

 

[CubsDynasty]

After 4 hours I just pull the epidural and do a spinal bc of failure rate. But it also comes down to NPO, otherwise it’s an interval tubal. Convenience vs safety.

 

[anonperson]

I currently work in a high volumen OB/GYN hospital. Today OB filed a complaint against one of our attendings because he will only do a tubal ligation 6 hours after birth. I usually have them wait 30 min after birth just to make sure there’s no bleeding or any funny bussiness (this is a teaching hospital After all).

I took a deep on this topic but I didn’t find anything conclusive, what’s you take on this?

There isn't much other than opinion based papers:

Postpartum Tubal Ligation: Safety, Timing, and Other... : Survey of Anesthesiology

An abstract is unavailable.

journals.lww.com

"Within 8 hours of delivery is reasonable"

From ACOG:

Access to Postpartum Sterilization

www.acog.org

They indicate every effort should be made for immediate post partum sterilization but don't give a time frame.

__________________________________________

Usually you will know if mom is stable within the first 30 to 60 minutes after delivery.

Waiting 6 hours is pretty arbitrary. The OB and Anesthesiologist both should just use common sense on the optimal timing for the specific patient.

Logistically, the sooner it can be done, the better or else the delays can mount.
______________________________________

I'm glad I'm at a facility that doesn't do post partum sterilization. They are a pain to schedule and do.

 

[Beeftenderloin]

We have 1 doc providing OB coverage in house for epidurals or emergency sections at any given time. As a department we’ve drawn a line stating that if the the OB on wants to do an elective tubal on a night/weekend they can use their emergency doc but we will NOT call a second doc in if the case that’s going is an elective tubal so they should think very carefully before using them for that purpose. Now they usually only happen on weekdays during business hours.

 

[aneftp]

This is the Problem with anesthesia. It’s a service dept. We are suppose to work at the disposal of other services.

I suspect ob had to go somewhere else rather than wait 6 hours to do a procedure. Or it was their ob patient so they felt obligated to do the procedure and didn’t want to stick around.

I see no other reason to file a complaint against another doc other than the selfishness of the ob.

Just my two cents.

As for the actual question. We all know all ob peri partum are considered full stomach pre and post. I think reasonable to wait 2 hours cause most bleeding complications from normal vaginal deliveries happen within the first hour.

But then I suspect the ob doesn’t even want to wait 2 hours…and that’s your answer. The selfish nature of the business.

 

[abolt18]

This is the Problem with anesthesia. It’s a service dept. We are suppose to work at the disposal of other services.

I suspect ob had to go somewhere else rather than wait 6 hours to do a procedure. Or it was their ob patient so they felt obligated to do the procedure and didn’t want to stick around.

I see no other reason to file a complaint against another doc other than the selfishness of the ob.

Just my two cents.

As for the actual question. We all know all ob peri partum are considered full stomach pre and post. I think reasonable to wait 2 hours cause most bleeding complications from normal vaginal deliveries happen within the first hour.

But then I suspect the ob doesn’t even want to wait 2 hours…and that’s your answer. The selfish nature of the business.

NPO was going to be my biggest concern. Especially because these days women are usually still allowed to eat and drink during labor. Many are eating right after they deliver. To me, the only limitation here is the NPO status because this is a 100% elective case.

Edit to add that the only elective tubals post vaginal delivery I have ever done were the next day.

 

[woopedazz]

Wouldn't this be an indication for cesarean? I've literally never done an elective open tubal ligation immediately post vaginally delivery.

Or just wait and do it lap? Who are these patients/obs who do vaginal --> elective open procedure? Am I dumb/ignorant?

Edit: how can a woman, hours after experiencing the most painful thing of her life, then give informed consent that she never wants to do it again. Whilst being absolutely sure she won't change her mind once the pain abates? I don't understand this.

 

[patriot6]

Wouldn't this be an indication for cesarean? I've literally never done an elective open tubal ligation immediately post vaginally delivery.

Or just wait and do it lap? Who are these patients/obs who do vaginal --> elective open procedure? Am I dumb/ignorant?

Edit: how can a woman, hours after experiencing the most painful thing of her life, then give informed consent that she never wants to do it again. Whilst being absolutely sure she won't change her mind once the pain abates? I don't understand this.

It’s almost always a situation where the mother has been consented previously. Like… in the 9 months leading up to delivery. And by “open”, they mean like a 2inch periumbilical incision. It’s nbd. Agree with others, npo is only consideration of mine.

 

[gcc322]

Wouldn't this be an indication for cesarean? I've literally never done an elective open tubal ligation immediately post vaginally delivery.

Or just wait and do it lap? Who are these patients/obs who do vaginal --> elective open procedure? Am I dumb/ignorant?

Edit: how can a woman, hours after experiencing the most painful thing of her life, then give informed consent that she never wants to do it again. Whilst being absolutely sure she won't change her mind once the pain abates? I don't understand this.

This is a common procedure post vaginal delivery…the uterus and tubes are in an optimal position for a small incision and relatively quick procedure. Fairly certain all the sterilization paperwork must be signed prior to hospitalization and delivery…definitely not something that can be decided on the spot.

I also think we will likely see fewer of these in favor of a lap saplingectomy due to ovarian cancer reduction.

 

[DirtDocMD]

Is his rule “6 hours”, or is it “6 hours for any birth after midnight”?? I can understand not wanting to do tubals at 3am…

 

[TxGasserMD]

This is a common thorn is our side at my hospital. Unfortunately we are the only hospital in my city to do tubals so patients come specifically there for delivery. Our OBs in the past had been accoustomed to getting to do any tubal when they want but we had to nip this in the bud due to staffing concerns. Now they are trying to get Admin to allow the practice to continue. Typically though during normal working hours we do PPTL whenever as long as there are no NPO or Hemodynamic issues.

 

[Dr. Rude]

This is the Problem with anesthesia. It’s a service dept. We are suppose to work at the disposal of other services.

I suspect ob had to go somewhere else rather than wait 6 hours to do a procedure. Or it was their ob patient so they felt obligated to do the procedure and didn’t want to stick around.

I see no other reason to file a complaint against another doc other than the selfishness of the ob.

Just my two cents.

As for the actual question. We all know all ob peri partum are considered full stomach pre and post. I think reasonable to wait 2 hours cause most bleeding complications from normal vaginal deliveries happen within the first hour.

But then I suspect the ob doesn’t even want to wait 2 hours…and that’s your answer. The selfish nature of the business.

We consider them elective “add ons” that is the biggest issue for the OBs. They are used to stat and urgent C-sections to be done smartly. Even labor epidurals that there is an expectation that someone will be at the bedside relatively timely. Hence we are “obstructionists” when we put these cases to the add on, non-urgent list.

 

[aneftp]

We consider them elective “add ons” that is the biggest issue for the OBs. They are used to stat and urgent C-sections to be done smartly. Even labor epidurals that there is an expectation that someone will be at the bedside relatively timely. Hence we are “obstructionists” when we put these cases to the add on, non-urgent list.

It’s a hard meeting to have. This is where a strong dept chief or anesthesia admin earns their money. Or else it as weak dept

Set standards. Written policy. Have it in place. Surgeons or procedurists will not be able to complain. Your chief needs to have that discussion with ob heads. It’s all about communication.

 

[GassYous]

This is a common thorn is our side at my hospital. Unfortunately we are the only hospital in my city to do tubals so patients come specifically there for delivery. Our OBs in the past had been accoustomed to getting to do any tubal when they want but we had to nip this in the bud due to staffing concerns. Now they are trying to get Admin to allow the practice to continue. Typically though during normal working hours we do PPTL whenever as long as there are no NPO or Hemodynamic issues.

Maybe admin can sit the room and watch the monitors then

 

[aneftp]

Maybe admin can sit the room and watch the monitors then

Notice admin will never schedule Friday 4pm meetings.

Most admin meetings are Tuesday -Thursday.

On their time

 

[coffeebythelake]

Elective means adhering to appropriate NPO time.

 

[UscGhost]

We usually say "patient safety". If it's after hours, the staff is tired and more prone to potential mistakes.

Also, mom and baby should be bonding and resting. Not rushing to the OR.

The tubal can wait until 630 or 7am

 

[IlDestriero]

We consider them elective “add ons” that is the biggest issue for the OBs. They are used to stat and urgent C-sections to be done smartly. Even labor epidurals that there is an expectation that someone will be at the bedside relatively timely. Hence we are “obstructionists” when we put these cases to the add on, non-urgent list.

This is the problem. They forget GYN time and patient acuity and triage of limited resources. As for timing, NPO status should dictate practice as that’s the standard of care for elective surgery regardless of if you will consider them full stomach anyway. Doing something 30 min after delivery is stupid and should be called out as such. What’s a reasonable minimum? Maybe 2 hours? That’s what I’d push for as it is 100% elective and you probably need a couple of hours of data post delivery to confidently say they’re stable without bleeding. It also passes the common sense test. Filing a complaint for refusing at 30 min passes the stupid test. That dope would never get any consideration for anything moving forward.

 

[Angus Avagadro]

It's still an elective case. Why would we treat it differently? If we do, then other surgeons will want to know why we don't do the same for their patients. It's all for the OBs convenience. No different than the weekend elective induction. The only indication for that I have seen is the OB is on call that weekend. It is a real headache for smaller OB units.

 

[coffeebythelake]

Filing a complaint for refusing at 30 min passes the stupid test. That dope would never get any consideration for anything moving forward.

Agree. Anyone so petty to complain about this to the hospital admin is a petulant clown and goes on the sh1tlist.

 

[IMGASMD]

Haven’t been to that many hospitals yet. But never have I done a tubal after vaginal delivery. C-sections, sure. Vaginal no. It’s an elective procedure…. They can wait.

 

[Realgassy]

When I was a resident, I remember getting a call at 3am to do a tubal after vaginal birth at the county hospital. I pushed it to the next day, because I really didn’t understand the need to do anything non emergent at 3am.

I got chewed out by the OB anesthesia attending the next day as she considered it urgent. I understood her perspective on health disparities and the likelihood of in happening decreases dramatically if it doesn’t happen soon after delivery. The patient is much more likely to leave the hospital and then come back with an unwanted pregnancy.

This hasn’t come up again for me as I would describe the OB practice I cover as boutique. Neither the patients nor the attending want to do anything in the wee hours. I would agree with proceeding 2hrs after delivery during the day.

 

[gunnershow]

When I was a resident, I remember getting a call at 3am to do a tubal after vaginal birth at the county hospital. I pushed it to the next day, because I really didn’t understand the need to do anything non emergent at 3am.

I got chewed out by the OB anesthesia attending the next day as she considered it urgent. I understood her perspective on health disparities and the likelihood of in happening decreases dramatically if it doesn’t happen soon after delivery. The patient is much more likely to leave the hospital and then come back with an unwanted pregnancy.

This hasn’t come up again for me as I would describe the OB practice I cover as boutique. Neither the patients nor the attending want to do anything in the wee hours. I would agree with proceeding 2hrs after delivery during the day.

Perfect example of why no one takes "OB anesthesia" attendings seriously. Other examples include them arguing over phenylephrine vs ephedrine and blue tape vs silk tape.

Stick a nexplanon in if they're so concerned.

 

[anbuitachi]

When I was a resident, I remember getting a call at 3am to do a tubal after vaginal birth at the county hospital. I pushed it to the next day, because I really didn’t understand the need to do anything non emergent at 3am.

I got chewed out by the OB anesthesia attending the next day as she considered it urgent. I understood her perspective on health disparities and the likelihood of in happening decreases dramatically if it doesn’t happen soon after delivery. The patient is much more likely to leave the hospital and then come back with an unwanted pregnancy.

This hasn’t come up again for me as I would describe the OB practice I cover as boutique. Neither the patients nor the attending want to do anything in the wee hours. I would agree with proceeding 2hrs after delivery during the day.

i hope you left with zero respect for that attending.

 

[Dantrolene FC]

At my hospital, if the patient had a vaginal delivery with an epidural, they go overnight within two hours of delivery for their tubal. If they didn't have an epidural, they go the next morning with a spinal.

 

[anbuitachi]

At my hospital, if the patient had a vaginal delivery with an epidural, they go overnight within two hours of delivery for their tubal. If they didn't have an epidural, they go the next morning with a spinal.

do they tell you in advanced? i pull out epidural pretty fast after delivery

 

[Dantrolene FC]

do they tell you in advanced? i pull out epidural pretty fast after delivery

The nurses remove all the epidurals 24/7, unless we specifically tell them not to, such as in the case of thrombocytopenia or coagulopathies. They just call us and say they’re ready for a tubal.

 

[Maz777]

At my hospital, if the patient had a vaginal delivery with an epidural, they go overnight within two hours of delivery for their tubal. If they didn't have an epidural, they go the next morning with a spinal.

That is rather nuts. What woman would want a significant operation in the middle of the night right after pushing a baby out? This has to be forced by the OBs wanting to get wRVUs/compensation. Or they have completely fed into the ACOG propaganda. Let them get some rest and do it in the morning with a proper spinal. A tubal isn't the only long-acting contraceptive. Someone needs to publish a retrospective study of tubal ligation outcomes based on the time of day they are performed. Just please find one increased type of complication. That's all I ask. Any takers?