Contraception - Permanent methods: Nursing

Permanent methods of contraception are surgical procedures that permanently prevent future pregnancies. So, for individuals assigned females at birth, tubal ligation surgery is done to achieve permanent contraception, while in the case of individuals assigned males at birth, vasectomy is performed.

Of note, even though they are widely accepted as “irreversible” methods, in some situations, these procedures can be reversed.

Now, to understand the tubal ligation and vasectomy, let’s start by having a look at the anatomy and physiology of the fallopian tubes in assigned females and the vas deferens in assigned males at birth.

The fallopian tubes, also known as oviducts or uterine tubes, are a pair of tube or pipe-like structures on each side of the uterus that connect it with the ovaries.

This way, during the menstrual cycle, it helps in transporting the ova or oocyte from the ovary to the uterus. Each fallopian tube has four sections: the uterine section, which opens into the uterus; the isthmus, which is the tightest part of the tube; the ampulla, which is the widest part of the fallopian tube where fertilization usually occurs; and the infundibulum, which envelops the ovary with finger-like projections called fimbriae.

Switching gears, let’s look at the anatomy of the vas deferens, which refers to a pair of thick long tubes that carry mature sperm from the epididymis to the ejaculatory ducts.

The ductus deferens begins at the inferior pole of the testis, then ascends posterior to the testis to enter the spermatic cord, which connects the testes to the abdominal cavity.

From there, the ductus deferens enters the pelvic cavity and goes over the bladder, and then descends medial to the seminal vesicle.

The ductus deferens then terminates by joining the ducts of the seminal vesicle, forming the ejaculatory ducts which connect to the urethra.

During transport from the vas deferens to the urethra, the sperm collects secretions from the male accessory sex glands such as the seminal vesicles, prostate gland, and bulbourethral glands, which provide the bulk of semen.

During ejaculation, the semen leaves through the urethra. So, in individuals assigned female at birth, the operative procedure to achieve permanent contraception is bilateral tubal ligation.

It involves the use of clips, banding or cautery to clamp down the fallopian tubes, or the tubes can be removed altogether.

Most often, tubal ligation is done in a postpartum setting, either during a cesarean delivery, or 1 or 2 days after vaginal delivery.

Alternatively, it can be performed at a time unrelated to childbirth. Another technique of tubal ligation involves a non-surgical approach, where a nickel coil is inserted into the fallopian tubes.

Over time, as tissues grow in and around the coil, it slowly occludes the tubes, achieving mechanical blockage of fallopian tubes, which can then be removed or occluded with electrocoagulation.

The risk of pregnancy is extremely low following bilateral tubal ligation, however, in case it does happen, it comes with a high risk of ectopic pregnancy.

Similarly, in individuals assigned male at birth, a vasectomy can be performed to achieve permanent contraception, by blocking the sperm made by the testes from reaching the semen.

The procedure involves interruption or occlusion of each ductus deferens and is typically performed in an outpatient setting under local anesthesia.

Now, there are two methods for vasectomy. Conventional vasectomy is a traditional vasectomy approach which involves bilateral scrotal incisions through which each ductus deferens is mobilized and transected.

Another method is no-scalpel vasectomy, which is associated with almost little to no bleeding, less chances of infection, and pain.

A puncture is made through the scrotal skin overlying the vas deferens and widened only enough to externalize the vas deferens for transection.

Generally speaking, sterility is not instantaneous following a vasectomy. In fact, individuals are advised to use backup contraception until a semen analysis is done around 3 months after the procedure shows azoospermia, meaning no sperm in the semen.Okay, let’s move on to client and family teaching.

If your client has undergone a laparoscopic bilateral tubal ligation, explain that they may feel a little bloated after the procedure, due to the air that was used to enlarge their abdomen, to make it easier to see the fallopian tubes.

Reassure your client that this should resolve as the air is absorbed. If they experience mild pain, teach them to take their prescribed analgesic exactly as directed.

Also let them know that they may have a small amount of vaginal discharge, so encourage them to wear a perineal pad for the next few days.

Be sure to instruct them to avoid strenuous activities, sports, and lifting heavy objects for one week after the surgery.

Then, let your client know that they can shower 24 hours after the surgery, and caution them to avoid rubbing or pulling on their incisional site.

Advise them to leave the adhesive strips that are covering their incisions in place, and contact their healthcare provider right away if they develop a fever, or severe pain, bleeding, or excessive discharge from the incision site.Also instruct them to avoid sexual intercourse for the first week after surgery; after that, stress the importance of using an alternative method of contraception for at least three months after the procedure.

Remind them that although it is very rare to get pregnant after the procedure, pregnancies that do occur are often ectopic, where the embryo forms outside the uterus.

Underscore that an ectopic pregnancy is a very dangerous situation, and stress the importance of contacting their healthcare provider right away if they think they may be pregnant.

Lastly, emphasize the importance of keeping their follow-up appointments for continued care and monitoring. Now, if your client has undergone a vasectomy, begin by reassuring them that the procedure does not affect their libido or sexual performance.

Let them know that they may have mild scrotal pain and swelling after the procedure. Teach them to take their prescribed analgesic exactly as directed, and let them know that they can apply a cool pack to the area 2 to 3 times each day for no more than 20 minutes each time.

Then, discuss the importance of wearing scrotal support such as an athletic supporter for at least 2 days, and show them how to place a clean gauze pad inside the athletic supporter and over the incisional site to absorb any drainage.

Let them know that a small amount of blood on the gauze pad is normal, and to contact their healthcare provider if there is significant swelling, or if they need to change the gauze pad more than 2 to three times in a day due to excessive bleeding.

Also let them know that sometimes, a small painful lump called a sperm granuloma may form as a result of sperm leaking from the cut vas deferens.

Reassure them that this usually resolves as the body absorbs the sperm, and symptoms can be controlled with analgesics and scrotal support.

Next, instruct them to avoid strenuous activities, sports, and lifting heavy objects for one week after the surgery. Also let them know that they can shower 24 hours after the procedure, but to wait 48 hours before bathing.

Instruct them to gently pat their scrotum dry, and to avoid rubbing it.Remind your client that the vasectomy will not be effective immediately, and that multiple ejaculations will be needed to clear out the sperm that are present beyond the transection site.

Be sure to stress the importance of using an alternative method of contraception until there is confirmation that there are no sperm cells in their semen, which could take 2–4 months after the procedure.

Finally, instruct your client to notify their healthcare provider immediately if they develop a fever or have difficulty urinating.

All right, as a quick recap... Permanent methods of contraception refer to methods that permanently avert future pregnancies, including bilateral tubal ligation and vasectomy.

The tubal ligation procedure involves the use of clips, banding, or cautery to clamp down the fallopian tubes, or the tubes can be removed altogether.

The vasectomy procedure is performed by transecting the vas deferens to block the sperm made by the testes from reaching the semen.

General client and family teaching focuses on self-care to promote healing and prevent complications.