1. Tubal Ligation (Female Sterilization) Session IIIA: Counseling and Informed Consent
Introduce the session by informing the participants that the overall purpose of this session is to equip them with the knowledge, skills, and attitudes required to effectively carry out a counseling session for clients and couples who are considering female sterilization as their method of choice.
This third set of slides for minilaparotomy training covers the following topics:
A: Counseling and Ensuring Informed Consent for Female Sterilization
B: Preoperative Client Assessment and Preparation for Minilaparotomy
C: Basic Anatomy and Physiology of the Female Reproductive System
D: Pain Management,
E: The Minilaparotomy Procedure
F: The Subumbilical Minilaparotomy Procedure
G: Immediate Postprocedure Tasks, Postoperative Care, and Follow-Up
H: Preparing for Problems and Managing Side Effects and Complications
I: Practicing the Minilaparotomy Procedure

2. Objectives By the end of this session, participants will be able to:
List key counseling topics for female sterilization users
Define the terms informed and voluntary decision making and informed consent
List the factors contributing to sound decision making and possible regret
List the seven information elements of informed consent for female sterilization
Correct myths and misunderstandings on female sterilization
Explain the female sterilization procedure to the client
Support the female sterilization user before, during, and after the procedure
Practice counseling clients at different stages of female sterilization service delivery
Click to advance to the next objective and read each aloud.

3. Key Counseling Topics for Female Sterilization Users
Safety and effectiveness
How the method works
Health benefits
The procedure itself
Lack of protection against STIs, including HIV
Possible side effects
Pre- and postprocedure instructions
Ask: “What are key counseling topics that are important for a female sterilization user?”
Allow some responses, then advance the slide presentation to reveal the rest of the content.
Explain:
A client who is interested in female sterilization and who has made a decision to use this method should be informed of the following:
The method’s safety and effectiveness.
How the method works
Its health benefits
The female sterilization procedure itself, including how to prepare for the procedure, where and when it will be performed, what she will feel, how the provider(s) will take care of any pain and discomfort that she may experience, the duration of the procedure, and when she will be allowed to go home
When the contraceptive effect of the method begins to operate
The method’s lack of protection against STIs, including HIV (The provider should help the client assess her risk of contracting STIs, including HIV, and discuss the possibility of using the condom for protection, if needed.)
Side effects and possible complications
The recommended plan for follow-up after the procedure
What to do in the event that she experiences any problems in the immediate and late postprocedure period
Ask If there are any questions, and respond to these as needed.

4. What Is Informed and Voluntary Decision Making?
Informed and voluntary decision making is “the process by which an individual arrives at a choice of what to do about health care, based on options, information, and understanding.”
Ask: What is Informed and Voluntary Decision Making? Allow participants to respond to the question.
Display the answer to the question on the slide by advancing the slide show
Explain: informed and voluntary decision making is “the process by which an individual arrives at a choice or what to do about health care, based on options, information, and understanding”. . Make reference to some of the relevant response from participants as you read out the correct definition on the slide.

5. Verifying Informed and Voluntary Decision Making
How do you verify informed and voluntary decision making just before the procedure?
Ask: How do you verify informed and voluntary decision making just before the procedure?
Explain: A signed consent form does not always guarantee informed consent and that it is the duty of the surgical team to verify that the client has made an informed and voluntary decision to have the female sterilization. There a series of questions that the surgeon needs to ask the client to verify if the decision is a sound one. (see handout no. 6.) Distribute the handout and inform participants that you will revisit these questions during practice sessions. Such questions are meant to verify whether the client understands that the procedure is permanent, involves surgery and that there are risks associated with the procedure and whether she still wants the procedure. The surgeon and the team should also pay attention to the verbal and non verbal cues of the client, such as undue nervousness or restlessness.

6. Elements that Support Informed and Voluntary Decision Making
Service options are available.
Decisions are made without coercion.
Individual client or the couple have all of the appropriate information.
Respectful client-provider interaction - key to ensuring effective counseling
Rights are respected at the community and program levels.
Explain
There are five elements that support informed and voluntary decision making in reproductive health and they include:
Service options are available (i.e. for family planning there are a range of FP methods that includes short and long acting methods)
A voluntary decision-making process –ensuring that the decision is made by the client or couple without inducement or coercion with gifts, food, other services or monetary returns
Having all of the appropriate information (i.e., having an understanding of all options and their consequences)
A respectful client-provider interaction, (i.e. a friendly provider establishes rapport with the client, makes client relaxed, listens to the client, explains clearly to client, answers questions etc.)
Respect for rights at the community and program levels (i.e. woman’s right to make decisions on her reproductive intentions is respected by all at the community level and there are efforts at program level to empower and uphold respect of rights). Additionally, clients should also be made aware that even if she decides not to adopt or accept a family planning method, their decision will be respected

7. What Is Informed Consent?
Informed consent is “a medical, legal, and rights-based construct whereby a client agrees to receive medical treatment, such as surgery for a permanent method of contraception, or
to take part in a study based on knowledge of all appropriate and available options, information about these options, and an understanding of the relevant medical facts and potential risks associated with the methods/treatment options.”
Ask: What is informed consent? Allow a few responses, then display the correct definition of informed consent and review the definition.
Explain that informed consent is “a medical, legal, and rights-based construct whereby a client agrees to receive medical treatment, such as surgery for a permanent method of contraception, or to take part in a study based on knowledge of all appropriate and available options, information about these options, and an understanding of the relevant medical facts and potential risks associated with the methods/treatment options.”
Informed consent for female sterilization has key seven elements that the client should be aware of:
Knowledge of the availability of temporary methods
Understanding that female sterilization is a surgical procedure
Understanding of the benefits and risks of the procedure, including the small risk of failure
Understanding that it is intended to be permanent
Understanding that if the female sterilization is successful, the client will have no more children
Knowledge of the option to decide against the procedure at any time before the operation
Understanding that female sterilization does not protect the client or his/her partner from infection with sexually transmitted infections, including HIV
Counseling for female sterilization must cover these seven points of informed consent. In most programs, the client and the counselor also sign an informed consent form.
Source: EngenderHealth Taxonomy 2017

8. Key Characteristics of an Effective Counselor
Listens actively
Explores the client’s needs, thoughts, feelings, and circumstances
Tailors information to the needs of the client
Respects the client and her right to make her own decision
Helps the client make an informed and voluntary decision
Answers the client’s questions
Display the slide and ask the participants to describe the characteristics of an effective counselor. Allow a few responses, then advance the presentation to display each characteristic.
Explain:
Some of the key characteristics of an effective counsellor are that he or she:
Listens actively
Explores the client’s needs, thoughts, feelings, and circumstances
Tailors information to the needs of the client
Respects the client and her right to make her own decision
Helps the client make an informed and voluntary decision
Helps the client implement her decision
Answers the client’s questions
Allow time for discussion or questions, and explain each point, if needed.

9. Ensuring Sound Decision Making and Preventing Regret
Helping the client in the decision-making process…
Asking questions can help:
Do you want to have any more children?
If not, would you change your mind later? What might change your mind?
Suppose you lost your children?
Suppose you lost your partner; would you marry again?
Does your partner want more children in the future?
Factors contributing to possible regret
Young age
Having few or no children or having recently lost a child
Being unmarried
Marital instability
Having a partner who opposes sterilization
Making the decision under stress (during labor or immediately after delivery or immediately before or after an abortion)
Explain:
A woman or couple considering whether to adopt female sterilization should think carefully about the consequences of their decision.
To help the client or couple understand and therefore make a better choice, the provider can ask the client a number of questions that will help her make an informed choice. Such questions might include the following:
Do you want to have any more children?
If not, would you change your mind later?
What might change your mind?
Suppose you lost your children?
Suppose you lost your partner; would you marry again?
Does your partner want more children in the future?
If the client cannot answer these questions, she may need support, encouragement, and, most important, time to think further about the decision to have female sterilization.
Several factors may contribute to regret, including:
Young age
Having few or no children or having recently lost a child
Being unmarried
Having marital problems
Having a partner who opposes sterilization.
Making the decision under stress(during labor or immediately after delivery or immediately before or after an abortion)

10. Correcting Myths and Misunderstandings
Female sterilization does not:
Make a woman weak
Cause lasting pain in the back, uterus, or abdomen
Remove a woman’s uterus or lead to a need to have it removed, or turn the womb inside out
Cause a hormonal imbalance
Cause heavier bleeding
Produce changes in weight, appetite, or appearance
Change sexual behavior or sex drive
Ask: “What are some of the myths and misunderstandings about female sterilization that may be prevalent among communities within the facility’s catchment area.”
Explain:
Myths and misunderstandings can have negative impact on the acceptance of any method of family planning; therefore, it is important that provider(s) address the issue by providing the correct information.
The provider should always listen to the rumor, then share with the client what is the definition of a rumor. The provider should also ask the client more questions about the misunderstanding or rumor to gain a better understanding of the rumor, including the source of such information. The provider can then respond by providing facts (where possible, use scientific facts; always tell the truth; always clarify information and give examples; and reassure the client) and advising the client where to go for correct information about female sterilization and related issues.
Other mechanisms for providing correct information include campaigns, health talks through media, public speeches, and use of champions or key respected leaders to convey the correct information.
Responses to common myths and misunderstandings should be as follows:
Female sterilization does not:
Make a woman weak. The surgical procedure has no effect on the ability of the woman to perform her chores.
Cause lasting pain in the back, uterus or abdomen. During the procedure, the client is given medication to block pain and after the procedure, she is given medication that will alleviate pain. There should be no pain after the first few days unless there are other complications that need medical attention.
Remove a woman’s uterus or lead to a need to have it removed, or turn the womb inside out. The procedure does not involve removal of the womb or uterus or turning the womb inside out. What the trained provider does is to block the fallopian tubes, which carry the egg or ovum from the ovary to the uterine cavity, by ligating and excising them. The woman will still have her uterus after the procedure, and she will continue to have her monthly periods.
Cause a hormonal imbalance. Female sterilization has no effect on the hormones produced by or circulating in the body; instead, it works by mechanically blocking the path of the egg before it can be fertilized by the sperm.
Cause heavier bleeding. Female sterilization has no effect on the menstrual cycle. Scientific studies have produced no evidence of any long-term problem with changes in the menstrual cycle. (Note that a woman’s monthly bleeding becomes less regular as she approaches menopause.)
Produce changes in weight, appetite, or appearance. Female sterilization has no effect on the metabolic functions of the body; it does not affect appetite and does not cause weight gain. During or immediately after the procedure, some clients may have nausea or vomiting, but this is short-lived and may be caused by the drugs given to alleviate or block pain.
Change sexual behavior or sex drive. Female sterilization does not have any effect on sex drive or sexual behavior. The woman will have her normal sex drive after the procedure.
Discuss some of the myths and misunderstandings that have been mentioned by the group and are not covered in the list on the slide, and discuss the most appropriate response with the correct information.

11. Explaining Self-Care for Female Sterilization
The client should understand what she is expected to do before, during, and after the procedure.
Self care is about:
What to do before the procedure
What to do after the procedure
Suggested rest
Wound care (keeping the site clean and dry, avoiding rubbing the wound)
What to do about common problems
Plan the routine follow-up visit (on Day 7)
Explain
During the counseling process, the client should understand what she is expected to do before the procedure, in terms of preparing to have the procedure, and what she should do once she has had the procedure.
This information is normally in the form of instructions on how to care for herself before and after the procedure. Ideally, the client should also receive written instructions, so that she can refer to them as needed. To verify that the client understands the instructions, the provider should ask the client to repeat the instructions in her own words. The provider may then help the client to fill any gaps in the information.
Before the procedure, the client should be instructed on the following:
Use another contraceptive until the day on which the procedure is performed.
On the day before the surgery, do not eat any solid food six hours before surgery; drink clear liquid until a few hours before the procedure.
If breastfeeding, continue to do so.
Wear loose-fitting clothing to the health facility
Do not wear any jewelry to the facility.
Clean the abdomen well.
If possible, come to the facility with a friend or relative, to help to the client go home after the procedure or take care of her baby, if needed.
After the procedure, the client should be instructed on the following:
Rest for at least two days, and avoid doing vigorous work or lifting heavy objects for at least one week.
Keep the incision site clean and dry for the first two days.
Avoid rubbing the wound.
Avoid sex for at least one week.
Attend the follow-up clinic as directed (on Day 7).

12. The Procedure
Medication helps you keep calm and helps to prevent pain.
The provider will give you an injection at the site where the procedure will be done, to block pain.
You will stay awake.
A small cut is made; it is not painful.
The tubes are blocked or cut.
The opening is closed with stitches.
Rest a few hours.
Small cut either here
or here
Ask: “What does a woman who has chosen female sterilization need to know about the procedure (i.e., what will happen to her during the procedure)?”
Arrange to have one of the cotrainers to list all of the participants’ responses on a sheet of flipchart paper as they are mentioned.
Allow some time for the participants to mention as many points as possible. Stop the brainstorming when there is significant repetition of what has already been listed.
<Display slide>
The list should include:-
A woman who has chosen female sterilization needs to know what will happen during the procedure.
The client should also know:
When and where the procedure can be done
How long it will take
The type of anesthesia that will be used
What to expect in terms of pain
How long the she will stay at the hospital
How long the she will not be able to work
Possible risks and complications
How the procedure might affect her sexual relationships (including when she can resume sexual activity)
Postprocedure care and follow-up
The explanation by the counselor should include the following:
Female sterilization is a simple surgical procedure that can be done at any properly equipped health facility.
Prior to the procedure, the provider will perform a physical examination and a pelvic examination to rule out any problems.
The client will stay awake throughout the procedure.
She will receive medication in the form of light sedation and an analgesic to help her relax or keep her calm. Local anesthesia is injected at the incision site; all of these medications help to prevent pain.
The provider will use proper infection prevention procedures at all times, to reduce the risk of complications.
A small transverse incision is made in the abdominal wall at the location where the local anesthetic was infiltrated.
The provider then locates each tube, ties it, and cuts it.
The provider then closes the wound with stitches.
The client may feel a bit sleepy or drowsy, but this will fade away after a period of rest.
She will rest for a few hours before she is allowed to go home, with instructions and some medication for pain relief.
Identify from the list those points that should not be included in the discussion about the procedure with the client by stating reasons why this is so.

13. After the Procedure You should rest for 2 or 3 days.
Avoid heavy lifting for one week.
Do not have sex for at least one week.
Explain:
After the procedure,
The client should rest for at least 2–3 days.
She may continue to feel some pain at the site of the incision, but this should go away within the first few days.
She should avoid scratching, rubbing, or washing the incision site.
She should also avoid lifting heavy objects for one week.
She can have sex as soon as she is comfortable; this is usually after at least seven days.

14. Medical Reasons to Return
In first week, come at once if you have:
High fever
Pus or bleeding from wound
Pain, heat, swelling, redness of wound
Steady or worsening pain, cramps, tenderness in belly
Fainting or very dizzy
At any time in the future, come at once if:
Explain:
The client should be informed that she is welcome to come back to the clinic at any time after discharge if she is experiencing a problem, has questions, or thinks that she may be pregnant.
The client should also receive instructions that immediately after discharge and within the first week, or any time in the future, she should come to the clinic or health facility if she notices any of the following:
High fever with temperature above 38o C
Bleeding, pain, pus oozing from the wound, or heat, swelling, or redness of the wound that becomes worse or does not go away
Steady or worsening pain, cramps, and tenderness in the belly
Symptoms of pregnancy
Fainting, persistent lightheadedness, or extreme dizziness
You think you may be pregnant
Feel pain or tenderness in belly, or fainting
Source: WHO Decision Making Tool for FP for Clients and Providers 2005

15. Role Plays
Inform participants that you will shortly be demonstrating a counseling session. What you want them to observe is how we demonstrate characteristics of an effective counselor. Display slide # 7 (key characteristics of an effective counselor) and quickly go through these characteristics.
Instruct the participants to observe a counseling session that you are about to demonstrate and note any points for discussion later.
Perform a demonstration of counseling session with one of the co-trainers as the client opting for female sterilization. Use the provider and client instructions on Appendix C of the facilitator’s guide: Facilitating role plays.
At the end of the demonstration, inform participants that they will receive the feedback from the person who played the role of the “client” guided by the following questions
Were you satisfied with the counseling you received?
Were all of your questions answered?
Were you able to make your own decision?
Then ask the person who played the role of the provider and he/she will tell us how he/she feels
What did you do well in this counseling session?
Is there anything you would like to improve or do differently next time you counsel a client?
After the feedback from the provider ask the participants to comments first on the positive aspects of the counseling, then which areas need improvement.
Conclude the session by once again displaying slide 7 and going through the characteristics of an effective counsellor and inform participants that they will have a chance to practice later during the model as well as in the clinical area