BIG BABIES

These are the stories of some of the big babies that I have delivered over my career. One of these was in India in 1960. Usmana a Muslim woman aged 38 years came into the labour ward and she was well established in labour, she was obese weighing 96 kgs. This was her 7th baby she never had any antenatal care (ANC), never had any problems with any of her pregnancies or childbirth. She came to the hospital as she wanted a tubal ligation so that she can also get a transistor radio which the Indian government was offering to all those couples who had a tubal ligation. This was to promote family planning in India. This was an enormous size baby lying as breech (bottom first). Her blood pressure was mildly elevated 146/90; her urine was loaded with sugar (Probably gestational diabetes). She was well advanced in labour her cervix was 8 cms (almost fully dilated). Luckily the presenting part was well down. I was very worried about the delivery, particularly the after coming head and post partum bleeding. Luckily she delivered so fast, I did not have to do anything. I gave syntocinon for the placenta which followed soon after.  There were no tears or bleeding. A glucose tolerance test which we did within 24 hours of delivery,(as is advised) confirmed gestational Diabetes. It was a male infant weighing 7.2 kgs’, it required care and treatment because of mothers gestational diabetes. I had to start believing in GOD even if I never did before this incidence; there were many situations that happen during obstetric practice that takes your faith to GOD.

The next case that happened was in 1978. This was a normal twin pregnancy which had regular ANC, but the babies were enormously big for twins. It was my practice to rest twin pregnancies in hospital from 28 weeks to 34 weeks in the hope of preventing premature labour which I did in this case as well. The babies were growing bigger every day; I decided to do an elective Caesarian Section (CS) at 38 weeks. Both babies were happily delivered; they were both females and weighed 7.5 pounds each. I felt safer in delivering them by CS, being such big babies the mother was 36 years of age and a primigravida. I followed these girls for many years I was advised that they were growing well and doing well at school.

The next woman I delivered was in Australia in 1986. By now I was an expereriened senior obstetrician. This woman was a recent migrant from Lebanon. She was aged about 37. She was not sure about her age, but this was the age in her passport.

She had had 12 children in Lebanon without any ANC or care during labour. All the children were alive and well. A very lucky family. She arrived in Melbourne about 30 weeks of pregnancy. When I saw her she was about 32 weeks pregnant. All her blood tests were normal. It is a routine in Melbourne to test all pregnant women for diabetes. This was very important in this case as she was obese weighing110 kgs, her B.P was normal. She had had 12 children ( the risk of gestational diabetes was very high in this woman because of her parity, age,obesity and this baby being very large) luckily for her she had a normal glucose test and no gestational diabetes. On Ultrasound it was estimated that the baby’s birth weight will be about 12 lbs. She did not know the weights of her previous babies, she thought they were average. This baby was almost always lying in different positions (Unstable lie) this is a serious complication of later stages of pregnancy. They baby can have a cord prolapse or even a hand prolapse then it can become very difficult to save the baby, and even the mother. I suggested to her and the family that we should deliver this by caesarean section, I had great difficulty in convincing the mother. I finally called her Priest who convinced her. A male baby was delivered by caesarean section and even this was difficult due to the position that the baby was lying in. The baby weighed 13.3 lbs and he did well.

I was greatly delighted when I was invited to his 21 birthday party and his mother was telling me he is the best of her 13 children. He had grown up into a handsome boy who was a charted accountant and played in a band.

The next biggest babies were born to a German couple. They were both about 6 feet tall, well built, very healthy with a good life style and they came to me for their first pregnancy at ten weeks. The pregnancy progressed well. They had told me that they were themselves big babies when they were born and weighed about 8 to 9 lbs. This labour started well, she required an epidural for pain  relief and normal labour progressed. She had a normal vaginal delivery of a male baby weighing nine lbs and two ozs in good condition with a good *apgar, with an episiotomy.

*(APGAR- measures the following in a baby-Activity (Muscle Tone), Pulse, Grimace (Reflex Irritability), Appearance (Skin Colour), Respiration).

No dramas, no Post partum haemorrhage. All went well. Two and half years later she came back to me for her second pregnancy. This time the pregnancy progressed well. She had no Gestational diabetes. This baby was also a big one, the ultrasound estimate of the foetal weight was ten and half lbs, I felt a bit anxious, but I knew that she had a well shaped big pelvis, and we would manage. This time she had a very quick and easy labour, she did not require even pain relief, however I repeated the episiotomy. He was born with good apgar weighing ten lbs four ozs. I felt happy.

Three years later I saw her for her third pregnancy. Now she was 34 years of age still well, she had not put on any weight, her blood pressure was normal, her glucose tolerance test was normal. Towards the end of the pregnancy I realised that this baby was really big. Estimated foetal weight was twelve lbs. I discussed caesarean section with her. Finally we agreed to give a trial of vaginal birth and if at anytime I felt that there was a problem I would do a caesarean section. Luckily she agreed. Labour progressed slowly with the help of an epidural. Towards the end the second stage was slow, that is, that it was longer than average for the baby to be born after full dilatation of the cervix. I delivered the baby by forceps, with a good apgar. Again it was a male baby, weighing 12lbs and 9 oz. There was some excess bleeding but not amounting to Post partum haemorrhage, which is when the bleeding is more than 500 mls.

I was in touch with the family for a long time; all the boys became involved in sports.

This story is of a big mother (Very Obese) who had a very big baby. This also showed me how I would get some sort of sixth sense about my patients .Christine was admitted to the hospital at 38 weeks of pregnancy as she was not feeling well.  At 9 pm I saw her and she was not too bad, her blood pressure was border line high 140/90, the urine was clear foetal heart monitoring was normal. I advised some sedation for her with a view to review her in the morning. In the middle of the night I felt like that I should go and see her now. When I got there the baby was very restless, the foetal heart sounds were non reassuring, I decided to do a caesarean section immediately. It was not an easy task because of the mother’s weight; the baby proved to be very big, with the cord round the neck (I wonder if that caused foetal distress), the baby’s extraction from the uterine cavity was not easy. It weighed 15 lbs and 6 ozs. It was the biggest baby I have ever delivered. The baby’s apgar was 7, it did well. There was a paediatrician present at delivery. The mother did not have gestational diabetes.

I understand that this baby remained big for many years. Maybe this was due to poor life style factors of the family. 

STORY ABOUT PEMPHIGOID GESTATIONIS OR AS IT WAS KNOWN BEFORE-HERPES GESTATIONIS

This story is about Mary a young mother of 26 years of age. She had a normal first pregnancy, two years ago. There was no history of any problems associated with that pregnancy. Her current pregnancy was going well. When she presented at 32 weeks for her routine antenatal visit she complained of severe itching and puritis around the belly button.  She also had a few blisters also around the belly button. There was some redness in her thighs as well. She said she was starting to itch very severely when I looked as these blisters; I immediately thought of a condition called herpes gestations or pemphigoid gestationis (PG). This is a very rare skin disorder which occurs during pregnancy only. It has nothing to do with ordinary Herpes. It’s frequency is quoted to be 1 in 70 000, or 1 in 2 million. I had never seen a case before, or ever since, but her very intense puritis and blistering around the belly button made me think of this diagnosis.

I urgently referred her to a colleague of mine, a skin specialist. He soon confirmed the diagnosis. The diagnosis is confirmed by skin biopsy and a technique called immunoflorescence test to look for antibodies. This may be a bit technical for you, please do not worry about it. PG is an autoimmune disease of pregnancy. There are many other diseases in our body which are autoimmune. Autoimmune diseases are a range of disorders, when an individual’s immune system produces an inappropriate response to its own cells resulting in damage to the tissues for example:  Rheumatoid arthritis. In PG, antibodies form in the skin, against a protein between the epidermis (the outer layer of skin) and dermis (the inner layer of skin) and then destroy the skin. What triggers this reaction is not understood. This diagnosis was confirmed by my skin specialist colleague. He advised the usual treatment of local Corticosteroids for itching. She also had some systemic Oral cortisol. To suppress the severity of the problems, she was also given some intravenous Immunoglobulin’s. These help to make the disease a bit milder.  There are many other drugs on the market which can be used for this purpose but they were not required in her case. The other complications in this situation are; premature delivery, foetal growth restriction, secondary infection and scarring. I watched her for all these. An ultrasound was performed every two weeks to make sure that the baby was growing well. She managed well with the treatment; however she did get some rashes on her thighs. She did not have any associated disorders. The main disorder that PG is associated with is autoimmune disorders of the thyroid gland, Graves’s disease (overactive thyroid) or underactive thyroid such as Hashimotos disease. Another condition that can happen and make pregnancy difficult is pernicious anaemia. Other skin disorders are not often confused with PG as the nature of the rash is different and the symptoms are different.

An ultrasound at 36 weeks suggested that the foetal growth was being compromised as the fluid around the baby was decreased more than expected. I induced her at the first opportunity by normal induction method. Her labour was easy; a male baby weighing 2.63Kg was born in good condition. The baby had a few rashes on the abdomen. This can happen in 5-10 % of babies, as the antibodies can pass through the placenta .She did not have any trouble in the post partum period as the rash had cleared within 3 weeks. She was discharged home happily. I did advise her not to use oral contraceptives as PD can recur with oral contraceptive. It can also recur during menstrual cycle. I fitted her with an IUCD for contraception. To the best of my knowledge she never had any further problems or another baby. I was very pleased with myself for making this very rare diagnosis in a flash and had a comfortable mother and a healthy and happy baby.

STORY OF ROUND WORMS

Nina came to our hospital in June1960; I was a bit more experienced as a doctor. It had been just over a year since I graduated. She complained of a lump on the lower left side of her abdomen, with frequent abdominal pain. She was a young girl of about 20 years of age and not married. She was nonvegetarian. She looked under nourished. She had not had a menstrual period for six months her blood count showed, what we call mild eisinophilia, we did not pay much attention to this , although Ascaris can cause an eisinophilic pneumonitis. This can happen even without Ascaris her ESR was raised. Surprisingly the stool examination did not show any Ascaris ova this means that she had an infection somewhere.  Genital Tuberculosis was fairly common in India in those days. This can cause pelvic mass and absent periods. We had very basic x-ray services and ultrasound was unknown in the sixties. A clinical diagnosis of pelvic tuberculosis was entertained. She was given Anti tubercular treatment for three months but nothing changed. It was decided to do a laparatomy: guess what we found. A lump made of 16 Ascaris worms totally sealed by the peritoneum, arising from the fallopian tubes. There were sixteen worms in all. They were all removed. No holes could be seen in the bowel. The abdominal cavity was cleaned and closed. Nina made an uneventful recovery. She was subsequently given more treatment to clean her bowel of any Ascaris. It was also explained to her about personal hygiene and the meat she consumed. The cause of her not having a period was probably due to her poor nutrition. Her chest x-ray was clear 

Ascaris is one of the most common worm infections in the world. About one billion people suffer from it. It is a big fat round worm,

which can grow up to 35 cmin length. It can go round different parts of the body via the blood stream. Initially it can cause eisinophilia in the blood which we ignored, as there were no Ascaris ova in the stool.  In gynaecological literature many cases of Ascaris in the fallopian tubes have been described, and the first one was in 1926. 

TRIPLET PREGNANCY

It was November 1962; it was the second day of my new job at Benares Hindu University where; the government had just opened a new medical school. I and another doctor, from the same medical school were appointed as lecturers in obstetrics and gynaecology, after getting our masters of surgery qualifications in Obstetrics and gynaecology and under the supervision of a professor of surgery.

It was up to us to establish the department, attend to the paper work, and do whatever else was required. It was my second day in my new job. There was a registrar on duty in the department and she called me at about 5 am to come to the hospital urgently. An ambulance was sent to pick me up, which was the general rule because this way we were assured, that we would arrive very quickly. When I arrived in the labour ward, there was this woman Sitara Devi aged thirty-four in very strong labour, shouting and howling. This was her seventh pregnancy. She had six other children, all girls at home between the ages of twelve and two. She had never had any problems with any of her other pregnancies. They lived in a nearby village, her husband was a rickshaw driver, and they had decided to have a tubal ligation hoping that this baby surely would be a boy. She had never seen a doctor or a doula during this pregnancy. When I saw her she looked weak and emaciated what else could I expect. Her blood pressure was on the low side, she had an enormous belly. There was no time to measure it, we started her on an iv infusion in case she bled. In this hospital there was an x-ray department, but it was so early in the morning and there was no time for all this. I was sure that this was at least a twin Pregnancy with too much fluid; I was hoping that the babies were not abnormal. Within the next five minutes she delivered her first baby. This was a female weighing 4.6lbs. I was starting to wonder if there were three babies. I had never seen a triplet pregnancy the incidence of triplets is quoted as I in 60 000 or 1 in 200 million. They are now commoner with assisted technology. In the next ten minutes she delivered her second baby this was also a girl. I gave her an injection called syntocinon so that she will not bleed even though I was suspecting a third baby. It was very silly of me. This baby was lying with feet first which meant it was going to be a breach birth so I had to do a breech extraction. The baby came out in good condition; it was also a little girl. These babies were identical.  I felt very sad for the couple as they had wanted a boy but now had nine girls. l left the labour ward telling my registrar to deal with them Sitara did very well. She went home after 4 days with 3 new healthy girls. They did not have a tubal ligation hoping for a son in the future. Nearly 55 years down the track I still wonder about these girls. At medical school I had another Asha in my class who had 8 sisters. They came from a good family, they all became doctors. I wonder if any of these sisters made something of their lives. 

INJURY TO THE VAGINAL VAULT AFTER DELIVERY (CHILD BIRTH)

Pyarai aged 22 was discharged home on the third day after a normal child birth. This was her third child. She was sent home with her mother. She was explained about contraception. According to the latest Indian rules we were happy to do a tubal ligation as this was her third child. Her age did not matter. She did not want this, we advised her to return in 6 weeks so that we could fit an intra uterine loop, that is what we used in those days, it was 1959. However to my disgust she was brought over by her alcoholic husband to the hospital at about 2.00 AM, with a loop of bowel hanging between her legs. I was horrified; I did not know what to say or do. Obviously he came home dead drunk and forcibly raped her, the soft vaginal wall tore and a loop of bowel came down, for a change this was an easy case. I first started an intravenous drip, put her head down, and examined the bowel made sure it was not damaged. I replaced it very gently, gave her antibiotics and repaired the torn vagina. We kept her in hospital for 5 days, seeing her husband’s behavior; my boss put an intrauterine device in for her before she went home. This was not   a routine, but we had to do it for her. These days we keep talking about cruelty at home, I have been seeing this as an obstetrician, particularly in countries like India for last 60 years. Nothing has changed, cruelty towards women continues. I so much wish that organizations, like The Melinda and Bills Gates charities, governments, Millennium Development program's, prevention of domestic violence can help these women with education equality and empowerment. Happy families make happy societies’, happy nations and in the end a happy world.

MOLAR PREGNANCY (HYDATIFORM MOLE)

It was still the month, of August 1959; I am still the junior most resident posted in the septic labour ward (labour ward for neglected women who were very ill). Najma a 37 year old woman from a nearby village came in, apparently in labour, with some bleeding, This was her fourth pregnancy; she did not know how pregnant she was. She conceived while she was breast feeding the last baby who was born two years ago. She never had any problems with her previous pregnancies. She had not seen a doula or a village doctor. She was on the obese side; we could not get her weight as she was not so well. I started to examine her; she had a fast pulse and a somewhat low blood pressure. On abdominal examination I was unable to feel any baby parts, there was no foetal heart. The abdominal girth was forty two centimetres. I tested her blood on my small pocket Haemoglobinometer (HB) which we carried in our pockets for emergency. The Haemoglobin was 2.  The average HB in Indian women is often between 8 -12.  In those days we had no Ultrasound (never even heard of it). The x-ray department was about half a kilometer away. The patient could not be moved in any case. It was five AM. I was not sure what was going on. Was it a twin pregnancy with massive fluid or was it a pregnancy with massive bleeding? I sent for my registrar who was a very capable doctor. We decided to put up an IV and emergency blood, which we used to keep O, Rh-negatives. It was only two units. In emergency we had to cross match blood for our need and bleed the donor. The pathology department was also far away in the main hospital. However one of my senior colleagues went to do this cross matching and took the relatives with her .My registrar came over and very gently tried to examine her, by now she was bleeding profusely and passing out tissue which looked like bunch of grapes. Both of us immediately got the diagnosis. It was what we call a molar pregnancy. We had exhausted our emergency blood, the cross matching blood was not yet ready as it takes nearly two hours, and the same doctor had to bleed the donors. The woman was bleeding like a tap, the whole big labour ward full of blood and within two hours of admission, she passed away, as if she had come to the hospital for dying. Her relatives were very angry. They wanted to kill me, as I was their first contact my registrar advised me to hide myself in the duty doctor’s room, in the bathroom, which I did. They hung around the hospital to find me and kill me, I was so frightened. However it all settled in the end. Our professor explained to all of them, that they have to take greater care of their mothers to be. From then on we had a regular flow of pregnant women from that village.

Molar pregnancy and many other complications of placental diseases, are together addressed as gestational (pregnancy) trophoblastic (arising from the placenta) diseases. Molar pregnancy is when; an abnormal fertilized egg plants itself inside the uterus and fails to grow like a normal baby. It is a disease of the placental tissue; it grows like massive tissues which look like grapes. The word mole simple denotes a mass of tissue .It is a noncancerous placental tumour, which can turn cancerous, it is then called Choriocarncinoma. Choriocarcinoma can also rarely arise after a normal miscarriage or a normal birth. There are two types of molar pregnancies, a complete mole or a partial mole; it is called a complete mole when an egg is fertilized by one sperm, all the female chromosomes die. The father’s chromosomes duplicate and make 23 pairs which is the normal chromosome number. No embryo, foetus or a normal placental tissue is formed. A partial mole is when the egg is fertilized by two sperm or one sperm duplicates, mother’s chromosomes remain, hence the embryo has 69 chromosomes. This happens if the egg has no nucleus or an inactive nucleus. Molar pregnancies are common among the Asian population say 1 in 100 as compared to western population where it happens 1 in 1000. The risk factors are, if you are of Asian descent, you are older than 40 (5times) or younger than 20 (1.5 times) you have had a previous mole (30times) and a previous miscarriage (twice as often). I have often seen molar pregnancies in young girls at the time of a miscarriage. It is a part of the same process of pregnancy failure. When a woman has a molar pregnancy she often suffers severe vomiting as compared to a normal pregnancy, intermittent vaginal bleeding and pelvic pressure pain. They can even pass grape like tissue pieces with their bleeding; they often get early rise of blood pressure or even like toxaemia of pregnancy which is a disease of late pregnancy. I have seen excessive vomiting causing liver failure in very malnourished young girls. Najma also had excessive vomiting; her blood pressure was never checked. On admission she had  low blood pressure as she had been bleeding, when a person bleeds the blood pressure goes down. A very small number of women may also develop symptoms of overactive thyroid that is they feel agitated, shaky, anxious, and cannot sleep. This happens because the very high levels chorionic gonadotrophins ( the pregnancy hormone in molar pregnancy )upset the control of thyroid  production. About one third of women with molar pregnancy also develop ovarian cysts on one or both sides because of high levels of pregnancy hormones. They almost always resolve, when the mole is gone. They are not cancerous.

In this day and age the diagnosis of molar pregnancy is easily made by ultrasound as early as eight weeks. Sometimes a vaginal ultrasound is required. The others tests that are done are to measure the blood levels of pregnancy hormones; a Thyroid function test, blood for haemoglobin and blood count, general liver and kidney function tests.

The treatment is simple under general anaesthesia in a hospital the molar pregnancy is removed by vacuum aspiration .Your clinician will explain all the details. All the tissue is sent to pathology. You will be able to go home in 4 hours. Rarely if the molar pregnancy is extensive or it is invading the uterus and you do not want any future pregnancies the uterus is removed.

After this initial treatment you require follow up regular pregnancy hormone tests and ultrasound to make sure there is no molar tissues in your body and your ovarian cysts have also resolved. Thyroid function tests and blood tests are also done to make sure that you are fully recovered. You are advised not to get pregnant for one year while the molar pregnancy is fully resolved.

In about 20 to 30 percent of Molar Pregnancies and rarely after a normal pregnancy and miscarriage a Choriocarcinoma (Cancer of the placental tissues) develops and it requires special investigation, treatment and follow up which we are not discussing in the post.

SURGICAL METHODS OF CONTRACEPTION

SURGICAL METHODS OF CONTRACEPTION

Sterilization for women and men 

What we need to understand

Sterilization with reference to family planning means permanent prevention from getting pregnant. For this to happen; the individual needs an operation. For women it is called tubal ligation or occlusion, for men it is called vasectomy. The partners need to consider it very carefully because it is permanent. Sometimes a single woman feels she never wants to have a baby and has a sterilization fairly young. I feel they need to think about it seriously. It can be reversed, however the success rate cannot be predicted. It also depends on the method of tubal ligation and what method was originally used.  If they were burned or totally removed it cannot be reversed.

pictures

Before the advent of so many methods of contraception, sterilization was very common. In countries like India, when India was trying to control its population the public was encouraged to use sterilization or vasectomy; if they did so they were given a transistor radio as a gift. It was unfortunate that many young men had a vasectomy in the greed of a transistor radio without understanding its serious consequences. Now since we have long term reversible contraceptives such as, intrauterine devices or hormone implants, the frequency of operative contraception has gone down.

VASECTOMY

It is an operative method of contraception for men. The tube called vasdeferens carrying the sperm from the testicles to the penis is cut and tied so that when ejaculation occurs, there are no sperm and the partner cannot get pregnant. This takes few months as the residual sperm will still be there. They are stored in the Epididymis as shown in the diagram below. A test is performed on your ejaculate before you are cleared for sexual relations and that there is no sperm. The sperm in your body is naturally absorbed, and there is no build up.  There may be infection or bleeding as a result of the operation but it is rare. Before you decide to have this operation performed, a man needs to think very carefully about the fact that he will no longer be able to produce any offspring however we now have the medical technology to freeze sperm should a child be desired. A vasectomy can be reversed however the results are uncertain. A vasectomy is simple and has less extra complications; it can be done under local anaesthesia.

TUBAL OCCLUSION

If you decide to have a tubal ligation, you and your partner should discuss that this is what you want. You may also discuss the alternatives with your doctor, maybe one of these appeals to you. Make sure you never want a baby or another baby. It is better if you are, older than thirty years of age. Research has shown that women often regret if they had a tubal ligation very young. The frequency of divorce also complicates matters further. In modern times the tubal occlusion is almost always performed by keyhole surgery called, laparoscopy. In developing countries where there are no surgeons who can do it or there is no equipment, as this is expensive, it is done by open surgery. Give yourself time to think about it. Keep up with your regular contraception until the very last day or to the last tablet.

There are two ways, how tubal ligation is performed.

 OPEN METHOD

This means that you belly is cut open. This is like any other surgical operation. The operation is explained to you and your partner. You have to be very sure that you want this done. In some countries they coerce to have this done by giving you money or electronic, goods. In my view it is safe if you have a good marriage, you have three children and you are above thirty years of age. After the basic things are decided, you go to the operating theatre after having given the, consent. The operation is generally done under general aesthesia by an anaesthetist. The surgeon then makes a cut near the bikini line, which is about 3-4 cms long. He then identifies the tubes and blocks them.  Different methods are used by different surgeons to block them. The urinary bladder which lies in this area is always emptied, to prevent it from being injured. The belly is then closed by sutures that do not need to be removed. Generally you can go home the same day or the next day. This operation is called mini laparatomy. It is done when you are not pregnant and using a proper contraceptive. I had an incidence when a woman who had sex the night before her operation was due, thinking this cannot do any harm, She did not turn up for her six weeks visit in spite of my requests finally when she arrived, she was twenty weeks pregnant. It was worked out that she became pregnant the night before, as she did not use the condom that night which was her normal usual contraceptive. It is best to do tubal ligation soon after a period (Proliferative phase of menstrual cycle) when the woman is not likely to get pregnant .Tubal ligation can be done at the time of caesarean section, however the failure rate of these tubal ligations are slightly higher than the ones done when you are not pregnant. Also the other problem can often be that if the baby is found to have a serious medical condition and he can die, than it can be a disaster. I am not very keen on doing tubal ligation during the time of a caesarean section or at the time of an abortion, as at that time one may not be emotionally ready.

There are several methods of Tubal ligation usually named after the Surgeon who described them. There are different parts of the tube shown in the picture below.

It is best to lift up the tube in a tissue forceps, make sure this is the part of the tube where the blood supply is least. This protects the ovaries from their blood supply being compromised. The tube is then compressed, tied and cut. About one cm loop of the tube is cut and sent to pathology. This confirms that the tube was cut. It is also very useful in any medico legal situations if they arise in case the tubal ligation fails and the cut end of the tubes are diathermied to prevent recanalisation. We make sure there is no bleeding. This is done on both sides. The tubes are put back in the abdominal cavity. When the suture material is absorbed, the cut ends of the tube separate.

This method of tubal ligation is called Pomeroy’s method. It is very simple and can be taught easily. The failure rate is 1 per 1000 at the end of one year, 7.5 per 1000 at the end of10 years. There can be deaths due to bleeding or infection although it is rare. I have seen one death after a postpartum tubal ligation probably due to deep venous thrombosis.

The Aldrige method is more temporary, where the  Fimbrial  end of the tube is tucked in . It is good for a successful reversal.

A number of surgeons remove the whole tube. This can interfere with ovarian blood supply however the recent research has shown it to be protective against ovarian cancer.

 In another method called the Madleners methods, the tube are crushed at two points and tied. No tube is removed. I have seen two cases of hydrosalpinex (swollen tubes full of fluid) following Madleners tubal ligation.

Tubal ligation can also be performed via the vagina. The vaginal tubal ligation is hardly used anywhere in the world. It also has a high risk of infection. The tubal ligation even by laparatomy can sometimes be difficult if, a woman had many pelvic surgeries or infections, as this can make difficult to identify and lift up the tubes. If following a tubal ligation, you feel you may be pregnant see your doctor urgently. If it is an early pregnancy it can be aborted if you so desire otherwise   doctors can look after your pregnancy.  Tubal ligation as such does not do any harm to your pregnancy.  Always call your doctor if you have unusual pain, fever, abnormal bleeding, pain in the calf and any other problem that is worrying you. Complications of tubal ligation are generally minor and easily managed; your surgeon always discusses these with you.

KEYHOLE SURGERY OR LAPARASCOPY

Keyhole surgery is the method used in most countries. It is often not used if the woman is obese, or is likely to have pelvic problems which can make the identification and picking up of the tubes difficult. It is usually done under a general anaesthesia in a well equipped hospital by a properly trained surgeon. The surgeon explains the procedure to you. The complications, failure rate and reversibility is also explained to you depending upon the method he uses. After general anaesthesia, he then makes two cuts one near the belly button and other at the bikini line in the middle or to one side. The belly is filled with gas, he identifies the pelvic organs, once the surgeon has access to fallopian tubes, and he usually seals them off by using, Filshie clips or rings. Sometimes they burn them and then may or may not cut them. It is harder to reverse the tube once they have been burnt.  Filshie clips are expensive and require an extra gadget, so it is not often used.

Some surgeons often prefer either to do the removal of either the tubes, or do a removal of Fimbrial ends of the tubes only. Recent research has shown that it is protective against ovarian cancer, as most of the ovarian cancers seem to arise from the Fimbrial end of the tube. One ovarian cancer is prevented after 100 such operations have been performed.

A new surgical method of achieving tubal occlusion has been added to help women. This is called hysteroscopic sterilization.It is only available in limited countries. It can be done under light sedation even in the surgeon’s office.

The surgeon inserts a small titanium coil, going through the vagina into the uterine cavity and than going through the tubal opening deposits the coil in the tube this coil is called ESSURE. At present this is the only hysteroscopic method available. After this operation you have to wait three months so that your body has created scar tissue around it totally blocking your tubes. At the end of three months a special test is performed to make sure that in fact your tubes are blocked. During this time you have to continue using your normal contraception before they confirmed that they are blocked. This was considered to be a negative factor regarding Essure. The failure rate is higher than laparoscopic sterilization. Reversibility has been tried with some success.
In recent times there has been some controversy about Essure because many women have required repeat operations. Some of these women who had this done in many situations were already compromised because of obesity, previous surgery, and co-morbidities. The repeat procedure had to be performed under a general anesthetic, which was not completely satisfactory. In view of these recent objections, please be sure that you are happy to have this procedure performed upon yourself.