1. (Female Sterilization)
Tubal Ligation
(Female Sterilization)
Session IIIB Preoperative Client Assessment and Preparation for Minilaparotomy
Explain: The purpose of this session is enable to learn how to conduct a preoperative client assessment and prepare a client for minilaparotomy surgery.
Technical Resource Package for Family Planning
Contraceptive Implants Module
Session VI

2. Objectives By the end of this session, participants will be able to:
State the purpose of preoperative client assessment
List the components of preoperative client assessment
Describe the process of preoperative assessment
List the preoperative instructions given to clients in preparation for minilaparotomy
Demonstrate how to perform client assessment, using tools such as checklists and the MEC
Counsel the client in preparation for surgery
Demonstrate how to prepare the client for minilaparotomy
Inform the participants:
By the end of this session, they will be able to:
State the purpose of preoperative client assessment
List the components of preoperative client assessment
Describe the process of preoperative assessment
List the preoperative instructions given to clients in preparation for minilaparotomy
Demonstrate how to perform client assessment, using tools such as checklists and the MEC
Counsel the client in preparation for surgery
Demonstrate how to prepare the client for minilaparotomy
Ask if there are any questions, and provide responses as needed.

3. Why Should We Conduct a Preoperative Assessment?
To determine the client’s physical and emotional fitness for female sterilization by minilaparotomy
To determine whether she has medical conditions that increase risks
To confirm that the client still wishes to receive female sterilization
To prepare the client for surgery under anesthesia
Ask: “Why should we conduct a preoperative assessment?” Allow the participants to offer a few responses, then explain:
The main purpose of doing an assessment of the client’s health condition is to determine her physical and emotional fitness for female sterilization by minilaparotomy.
Other reasons are to:
Determine whether she has medical conditions that increase risks associated with the procedure and with the pain management regimen,
Confirm that the client still wishes to receive female sterilization (verifying whether she has made an informed choice and given her informed consent)
Prepare the client for surgery under anesthesia

4. Preoperative Assessment
Who should perform the preoperative assessment?
When should it be performed?
Who is ultimately responsible for making the final client assessment on the day of surgery?
Ask: Who should perform preoperative assessment? After 2-3 responses, explain:
Preoperative assessment can be performed by appropriately trained clinical personnel (nurses, midwives, clinical officers, health officers or medical assistants, and physicians) who can take the client’s history and perform the physical examination.
Trained nonclinical personnel can also take the client’s history using a standardized checklist, but they should inform clinical personnel and the surgeon of any abnormal findings before the physical examination is performed.
Clients assessed at a different facility several days before arriving at a site for the minilaparotomy procedure may need to be reassessed to confirm findings.
Ask: When should the assessment be conducted? Allow a few responses, then explain:
Client assessment should occur after counseling and before the surgery. Interval clients can be assessed a few days before the procedure is performed. However, the number of visits should be kept a minimum, to avoid increasing costs associated with transportation.
Clients who have been admitted in the same facility for delivery or postabortion care may not need a full history if such information is already documented in their records.
However, it is necessary for the surgeon to verify that a client is in good condition before surgery. If there are precautions, then a full history and examination is necessary.
Postpartum and postabortion clients generally do not need a repeat pelvic examination before the procedure.
At some facilities and during outreach services, clients are counseled, are assessed, and undergo surgery on the same day.
Note: Clients requiring special attention will need assessment or examination from a specialist. as appropriate. Additionally, the anesthetist may also perform a preoperative evaluation to plan for the anesthesia or advice on preprocedure management or care.
Ask: Who is ultimately responsible for making the final client assessment on the day of surgery? Explain: The surgeon is ultimately responsible for reviewing the client’s chart, physical findings, informed consent, and suitability for sterilization; this is done as a final medical assessment on the day of the surgery, before any medication is given.

5. Components of Preoperative Assessment
Includes:
Taking a medical history
Performing a physical examination
Carrying out laboratory exams if needed
Explain: The preoperative assessment entails obtaining a full medical history, performing a physical examination (including a pelvic examination), and conducting laboratory tests (where applicable).
Distribute Handout #7, on components of client assessment, and explain that the handout shows each component and gives details of the rationale for the assessment. Remind the participants that this is a resource for their later reading.

6. Taking a Medical History
General information, such as:
Age, occupation, and level of education
Obstetric and gynecologic history:
Number of pregnancies, parity, number of living children, last menstrual period, history of pelvic infection or other sexually transmitted infection, contraceptive use
Medical and surgical history, such as:
Any current medical conditions, respiratory and/or cardiac illness, current medications, allergies, smoking, and alcohol or drug use
Previous surgery (pelvic or abdominal) and previous experience with anesthesia
Explain:
The process of taking medical history is the same.
The client’s medical history can be obtained by the surgeon or by any other clinical staff member or trained nonclinical staff.
Most facilities have a female sterilization record or chart/booklet that includes all of the key items to investigate.
A medical history generally includes the following:
General information, such as:
Age, occupation, and level of education
Obstetric and gynecologic history:
Number of pregnancies, parity, number of living children, last menstrual period, history of pelvic infection or other sexually transmitted infection, contraceptive use
Medical and surgical history, such as:
Any current medical conditions, respiratory and/or cardiac illness, current medications, allergies, smoking, and alcohol or drug use
Previous surgery (pelvic or abdominal) and previous experience with anesthesia

7. Performing a Physical Examination
General condition and nutritional status
Weight
Vital signs
Auscultation of the lung and heart
Abdominal examination
Pelvic examination
Other examinations as indicated, including laboratory tests
Explain:
A complete physical examination should be performed on clients before surgery, as these findings act as important baseline findings and a point of reference for early detection of any deviation from normal, which may be an early sign of complications.
The client’s vital signs and general condition are also an important reference point during her recovery from medication before discharge.
A pelvic examination is necessary for interval clients.
In summary, the assessment covers the following:
General condition and nutritional status
Weight
Vital signs
Auscultation of the lung and heart
Abdominal examination
Pelvic examination
Other examinations as indicated, including laboratory tests
Laboratory tests should not be done routinely for all clients being prepared for female sterilization, unless medical conditions warrant such tests.
Clients need to be supported during the preoperative assessment; it is the responsibility of the health care provider to ensure that the client is comfortable and receives respectful care.
Clients should fully understand the importance of the assessment and provide verbal consent. As with other medical care, the provider should ensure that visual and auditory privacy are maintained at all times during the assessment. This can be achieved by observing the following:
Using a private space (ensuring visual and auditory privacy) for history taking and physical examination (e.g., taking the client’s history and conducting the examination without other clients or staff being present)
Covering the client’s body during the examination and avoiding unnecessary bodily exposure
Eliminating staff traffic during the examinations
Positioning the examination table away from the examining room door
Gently performing the physical examination and explaining what the client can expect at each step
Ensuring that access to clinical records is restricted only to essential staff
Conducting all discussions with the client so that they cannot be overheard
Not leaving clients unattended in the examination room or lying on the examination couch as the provider attends to other matters.
Introduce the participants to Handout #8 and review all of the components and how to use the guide during practice sessions.
Explain that the observation checklist is a shorter version of the learning guide, with only the critical steps that must be performed correctly in the correct sequence at all times.
The observation checklist is what the trainers will use to assess the participants’ performance.
Inform the participants that they will have a chance to use them during the practice on models and in the clinical area.
Note: It is also important to share a sample of client record/forms/charts or booklet that are meant for use with family planning clients, particularly those opting for permanent methods, and to review this with the participants, to ensure that they are familiar with documenting client assessment findings.

8. How Can a Provider Be Reasonably Sure that the Client Is Not Pregnant?
A provider can be reasonably sure that a woman is not pregnant if she has no symptoms or signs of pregnancy and meets any of the following criteria:
She has not had intercourse since last normal menses.
She has been correctly and consistently using a reliable method of contraception.
She is within the first seven days after normal menses.
She is within four weeks postpartum (for nonlactating women).
She is within the first seven days postabortion or following a miscarriage.
She is fully or nearly fully breastfeeding, amenorrheic, and less than six months postpartum.
From: World Health Organization Selected Practice Recommendations for Contraceptive Use. Geneva.
Ask: “How can you as a service provider be reasonably sure that the client is not pregnant?” Allow a few responses from the participants and ask all of them are familiar with a job aid that helps a provider determine whether a client is not pregnant through their history. Distribute copies of job aids at this point and lead a brief discussion on how to use them.
Explain:
This tool is important, particularly when you are taking the client’s obstetric and gynecologic history.
In situations when the client cannot remember most of the relevant information, you may need to perform a pregnancy test as part of the client assessment.
Review the different questions and how handout #9 could be used.
Conclude this session by informing participants that preoperative assessment is mandatory for all client being prepared for surgery and that there will be enough time to practice and master steps to ensure they are routinely performed.

9. Providing Preoperative Instructions to Clients
Preoperative instructions should be given after the assessment.
They should be simple and clear, preferably in a local language.
The provider should ask the client to repeat the instructions.
Additional written (printed) instructions (with illustrations for those who are illiterate) should be provided.
Instructions should include:
What to do a day before surgery
When to come to the clinic
Whether the client needs to be accompanied by a relative to the clinic (to take care of a baby, walk her home, etc.)
What to do after the procedure (wound care, resuming work, sex, etc.)
Warning signs of problems
What to do if she experiences any of the warning signs
A routine return date and where to go for follow-up
Explain:
Ideally, the client should receive preoperative instructions after the provider has completed the assessment and has informed the client about the findings of the assessment and whether she is still eligible for the procedure.
These instructions should be explained to the client in a simple and clear way, preferably in her local language or any other language she understands best.
It is appropriate to ask the client to repeat the instructions.
Written instructions should also be provided.
The information should include the following:
If the client is at risk of pregnancy, she should be helped to select and use another contraceptive method to avoid pregnancy during the waiting period
On the day of the surgery, she should avoid eating anything six hours before the procedure, but she can drink fluids until two hours before the procedure..
She should not take any other medication a day before the procedure, unless advised otherwise.
The client should wash her lower abdomen and perineum with soap and water on the day of the surgery.
The client should wear clean, loose-fitting clothing on the day of the procedure.
She should not wear jewelry to the facility on the day of the procedure.
If possible, the client should bring a friend to walk her home after the procedure or to take care of her child, if she had just delivered.
After the procedure, the client should:
Rest for 2–4 hours before discharge
Inform the staff if she has any pain that does not go away or increases in intensity or excessive dizziness
Keep the operation site dry for 1–2 days
Avoid rubbing the incision site for 1 week
Avoid any vigorous work in the first two days, and do not lift heavy objects for a week
Take medications as instructed by the health care provider
Return to the clinic after one week

10. Scheduling the Surgery
Clients without any preexisting medical condition that requires special attention can be scheduled at their convenience.
A waiting period of a few days may be beneficial.
In outreach services offering minilaparotomy services, the procedure can be performed on the same day.
Ideally, interval clients should be scheduled during the proliferative phase of the cycle.
Postpartum and postabortion clients should be scheduled within seven days of their procedure.
After using emergency contraception, a client can be scheduled for surgery within 7 days of next menses.
Explain:
Clients who do not have conditions requiring special precautions should be able to have surgery as soon as it is convenient for them.
A waiting period between counseling and surgery is sometimes advantageous, to allow the woman time to reflect on her decision, but it should not be mandatory.
For interval clients, female sterilization should be performed within the first two weeks of their menstrual cycle.
For clients with shorter cycles (e.g., 21 days), the procedure should be scheduled within the first week after the onset of menses, or as long as the provider is sure that the client is not pregnant.
For postpartum and postabortion clients, the surgery can be scheduled on any day within seven days of their procedure.
After using emergency contraception, a client can be scheduled for surgery within seven days of the next menses.

11. Verifying Informed Consent
Surgical team must verify that the client has signed the informed consent and understands procedure is permanent and that she can change her mind for LARCs etc.
All to be done before medication with sedatives or other premedication
Explain:
The surgical team must verify that the client has signed the informed consent and understands that the procedure is permanent and that she can change her mind and use long-acting reversible family planning, for example.
In situations where the client cannot read or write, the forms provide the client with an opportunity to use her thumbprint as her signature.
All of this must be done before medication with sedatives or other premedication are provided to the client.

12. Supporting the Client Just before the Procedure
Prepare the client emotionally for surgery.
Inform the client:
About the procedure in detail
About the medication she will receive
That she is free to ask questions at any time
If the client seems anxious or nervous, explore her reasons for this. If there are none, reassure her.
Additional supportive activities will be offered by one of the team members.
Explain:
On the day of the surgery, the staff should prepare the client emotionally for the experience of the surgery. She should not have had any solid foods for at least six hours before the procedure.
Staff will also ask her if she had washed her abdomen as instructed.
The client should be informed that:
A staff member will be with her before, during, and after surgery.
The provider will ask her to void urine and to change into a gown just before surgery.
She will also receive some oral and/or parenteral medication to relieve pain and allay anxiety.
Staff members will talk to her during the surgical procedure.
Staff members will also monitor her blood pressure, breathing and pulse rate through out the procedure.
She should tell the staff if she is nervous.
Her maximum cooperation will be required.
She will be assisted to get onto the theater table (couch).
The nurse will wash her lower abdomen (or the mid-section of her abdomen) with liquids that may feel soapy and cool.
She should not touch her abdomen after it has been washed with medicated solution.
She will be injected at the operation site with medication to prevent her from feeling pain.
A small cut will be made in her abdomen. (She can be shown the location of the incision.)
She may feel some discomfort or pain in some steps of the surgical procedure; if this happens, she should inform the staff, so she can be advised on what to do as the staff take measures to eliminate such pain.
After the abdomen is opened, the tubes will be identified, cut, and blocked.
The abdominal opening will then be closed.
She will then be allowed to rest for a short time before being helped off the bed, and she will then move to the next room, where she will continue to be observed.
The provider should also observe the client’s general condition; if she seems unduly nervous, this should be explored further, to determine the underlying cause. If no underlying cause is identified, the client should be reassured..
The provider may revisit the discussion on postprocedure instructions (i.e., what the client should do after the procedure and what the warning signs are).
Conclude the session by reminding participants that we shall be practicing client preparation during model practice and clinical practice with clients