1. Pre-service Education on FP and AYSRH
Session II, Topic 10 Tubal Ligation

2. What is Female Sterilization ?
A safe and simple surgical procedure that provides permanent contraception for women who do not want any more children.
It involves cutting or blocking the two fallopian tubes.
Other names are tubal sterilization, tubal ligation, voluntary surgical contraception, tubectomy, Bi-lateral tubal ligation.
The method is generally irreversible so informed consent is key
Ask students what they know or have heard about female sterilization
Compare their responses to the slides 2 and 3

3. What is Female Sterilization (continued)
Two surgical approaches most often used:
Minilaparotomy using local anesthesia and light sedation is the approved standard procedure for BTL. A small incision is made on the abdomen and the tubes are brought to the incision to be cut and blocked.
Laparoscopy – a long thin tube with a lens in it is inserted in the abdomen through a small incision; the tubes are visualized, blocked or cut.

4. Mechanism of Action
The fallopian tubes that carry the eggs from the ovaries are cut off and blocked.
Eggs released from the ovaries cannot move down the fallopian tubes to meet the sperm.
Works because the fallopian tubes are blocked or cut. Eggs released from the ovaries cannot move down the tubes, and so they do not meet sperm.
Ask students how female sterilization works
Explain the mechanism of action of BTL in preventing pregnancy as written on the slide
Show diagram of female reproductive organs on slide 5.

5. Diagram Showing the Female Reproductive Organs

6. Effectiveness of Female Sterilization
• Female sterilization is one of the most effective methods of contraception but carries a small risk of failure.
• It is 99.5% effective, which means that the failure rate of the method is 5 pregnancies per 1,000 during the first year following the surgery
• Varies slightly depending on how the tubes are blocked, but pregnancy rates are still low with all techniques.
One of the most effective methods is cutting and tying the ends of the fallopian tubes after childbirth.
Explain that:
• Female Sterilization is one of the most effective methods of contraception but carries a small risk of failure.
• It is 99.5% effective, which means that the failure rate of the method is five pregnancies per 1,000 during the first year

7. Effectiveness of Female Sterilization
In this progression of effectiveness, you can see that female sterilization is very effective.
Implants
Male Sterilization
Female Sterilization
Intrauterine Devices
Progestin-only Injectables
Combined Oral Contraceptives
Male Condoms
Standard Days Method
Female Condoms
Spermicides
More effective
Less effective

8. Advantages of Female Sterilization
• Permanent method of contraception which protects against risk pregnancies
• Nothing to remember, no supplies needed, and no repeated clinic visits required
• Does not interfere with sex
• Does not affect a woman’s ability to have sex
• Results in increased sexual enjoyment - no need to worry about pregnancy
• No effect on breastfeeding
• No known long-term side effects or health risks
• Can be performed immediately after delivery
Is effective immediately
Ask students what they think are the advantages and disadvantages of female sterilization since they know what it is and how it works.
What are the advantages and disadvantages of female sterilization
Supplement as presented on the slide 8 and 9.

9. Disadvantages of Female Sterilization
Requires minor surgery by a specially trained physician
Requires an operating room set-up
Considered to be permanent
Does not protect against STIs and HIV if at risk of HIV or STI he couple has to use condoms as well.
Limitation of physical activities for about one week
Related to surgical procedure:
May have pain and swelling over the operative site (diminishes in a day or two)
Superficial bleeding

10. When You Can Have Sterilization ?
Most women can have sterilization at any time
But may need to wait if:
Adapted from “ WHO , Decision making tool for family planning service providers and clients, Geneva, 2005
Explain to students that:
A woman can undergo female sterilization procedure almost any time that it is reasonably certain that she is NOT pregnant.
Flash the slide 10 and 11 and explain to students about the different times when female sterilization can be performed.
Tell the students that according to the scope of work for nurses and midwives, they cannot perform female sterilization, so clients who express desire to have the procedure should be referred to a facility where such services are available.
Some other serious health conditions
Gave birth between 1 and 6 weeks ago
May be pregnant
Infection or other problem in female organs
Source: WHO decision making tool for FP2005

11. Time for Performing Female Sterilization
Postpartum
• Immediately or within seven days after giving birth
Interval
• From six weeks after childbirth if it is reasonably certain that the woman is not pregnant (see handout for screening to check if client is not pregnant)
• Within seven days after the start of the woman’s menstrual cycle
• At any time if it is reasonably certain that the woman is not pregnant

12. Time for Performing Female Sterilization (continued)
During caesarian section
If switching from oral contraceptives, she can continue taking the pills until she has finished that pack
After using emergency pill - within 7 days after she starts her menstrual periods
Post abortion: Within 48 hours after uncomplicated abortion.

13. Who Can Have Female Sterilization
All women can have female sterilization.
Including women who;
Have no children or few children
Are not married
Do not have husbands permission
Are young
Just give birth within the last 7 days
Are breast feeding
Are infected with HIV whether or not on ARVs
No medical conditions prevent a woman from using female sterilization.
Explain that:
With proper counseling and informed consent, any woman can have female sterilization safely.
No medical conditions prevent a woman from using female sterilization.
Provide students with Handout # 1 and explain how screening is conducted for female sterilization.
Flash the slides 13, 14, and 15 which show MEC for female sterilization to determine who can and who cannot use the method

14. Who Can Have Female Sterilization (continued)
In the checklist (hand out):
Caution means the procedure can be performed in a routine setting but with extra preparation and precautions, depending on the condition.
Delay means postpone female sterilization. These conditions must be treated and resolved before female sterilization can be performed. Give the client another method to use until the procedure can be performed.

15. Who Can Have Female Sterilization (continued)
Special means special arrangements should be made to perform the procedure in a setting with an experienced surgeon and staff, equipment to provide general anesthesia, and other backup medical support.
For these conditions, the capacity to decide on the most appropriate procedure and anesthesia regimen also is needed. Give the client another method to use until the procedure can be performed.

16. “Come Back Any Time” Reasons to Return
In first week, come at once if:
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
Explain that:
Although they do not perform female sterilization and that they are not expected to manage complications, it is important that they know the signs of complications.
Enumerate the warning signs as presented
Assure every client that she is welcome to come back any time- for example if she has problems or questions, or she thinks that she might be pregnant. A few sterilizations fail and the woman becomes pregnant.
At any time in the future, come at once if:
You think you may be pregnant
Pain or tenderness in belly, or fainting
Source: WHO Decision Making Tool for FP for Clients and Providers 2005

17. Counseling Process: Client has Selected Female Sterilization
Key counseling points to check for before procedure of referral for procedure:
That client understands that:
This is a permanent method
There are other options that they can use that are just as effective like Implants and IUDs.
She will have the surgery under local and might experience some pain after the procedure for first few days.
Method does not protect against HIV and STDs she will have to use condoms of at risk
Review the 6 Points for informed consent:
Clients must understand the following: that temporary methods are also available, voluntary sterilization is a surgical procedure, there are certain risks of the procedure as well as benefits, if successful is permanent, client can decide against the procedure at any time before it takes place.
Divide students into small groups
Ask each group to choose a client and a provider. Ask other members to act as observers and explain that they will give a feedback after the role play
Ask students to try and have as each student play the role of provider in turns
Ask observers use the Observation checklist and be ready to give feedback after the role play on:
Counseling skills used and not used
Important information give and left out.
Discuss female sterilization mechanism of action, advantages, disadvantages, and warning signs of complications.
Correct rumors and misconceptions
Demonstrate counseling skills (active listening, paraphrasing, encouraging, asking open ended questions)

18. Counseling a Client for Female Sterilization
Determine that the woman is not pregnant.
Assess client’s reproductive needs, risks for STIs, status of relationship with partner, and knowledge on FP method.
Use the FP Service record cards (or any approved assessment form) as a tool for undertaking assessment.
Use appropriate types of questions (i.e., closed, open-ended, probing) during assessment of the client.

19. Counseling a Client for Female Sterilization (continued)
Describe available family planning (FP) methods based on client’s reproductive need.
Discuss BTL as a FP method in terms of: Definition, Mechanism of action., Effectiveness, Advantages and Disadvantages, Possible side effects
Correct rumors and misconceptions.
Identify the reasons for clients’ return visits.

20. Counseling a Client for Female Sterilization (continued)
Ensure informed choice and consent form signed – clients must understand the following:- that temporary methods are also available, voluntary sterilization is a surgical procedure, there are certain risks of the procedure as well as benefits, if successful is permanent, client can decide against the procedure at any

21. Summary A woman considering sterilization should think carefully:
“Could I want more children in the future?” Health care providers can help the client think about this question and make an informed choice. If the answer is “Yes, I could want more children,” another family planning method would be a better choice.