By Melinda Young

Among the 600,000 permanent contraception (PC) procedures performed in the United States each year, most procedures are performed postpartum,
including after cesarean deliveries.^1,2 Through 2019, most of these procedures involved tubal ligation, but that has changed as evidence shows that salpingectomy has the additional benefit of reducing the risk of ovarian cancer.³

It can take years for new scientific evidence to make its way into clinical practice. Clinicians can help efforts to improve patient care by reading literature and guidelines regarding salpingectomy and adopting better strategies for counseling patients and handling the logistics of making desired salpingectomy procedures happen in the postpartum period.

Logistics can be a major barrier. “When I was an intern, I remember we had a patient who wanted to have a tubal after vaginal delivery, and I hadn’t been in that situation before, and when I went to our chief and asked her what we could do, she was exasperated because [doing the procedure] depends on the multidisciplinary team,” says Kathryn Crofton, MD, a complex family planning fellow with a subspecialty in OB/GYN at Rush University Medical Center in Chicago.

Attitudes toward permanent contraception among the medical team also can be a factor in whether the patient obtains the method they choose, she notes. “We found a candidate appropriate for tubal after vaginal delivery, and the charge nurse said, ‘We really want this for her and want to get this done,’ and the physician said, ‘It’s not what we want — it’s what the patient wants,’” Crofton recalls. “This made me curious. I looked at prior research and factors involving permanent contraception in general and after vaginal delivery.”

Crofton found that when patients had an uncomplicated vaginal delivery that did not require use of an operating room, their request for permanent contraception was labeled as elective instead of urgent or emergency. This meant the patient may have had to wait — sometimes for an entire day before an operating room would be available, she says.

The patient’s ability to obtain the procedure would depend on hospital logistics and care team factors, making it less likely the postpartum permanent contraception would occur. “There is inherent bias and discrimination built into this ad hoc situation,” Crofton says. “This is [true] for someone who has a documented history of saying, ‘When I have my baby, please take my tubes.’”

When labor and delivery staff triage patients, they will handle emergency cases first. But it is up to their perceptions about which additional cases involve an elective procedure, she adds. “Unlike someone who has their gall bladder taken out and who has a surgery time scheduled, postpartum permanent contraception procedures are not something we can plan for,” Crofton explains. “It’s much harder to plan it for someone who is going to deliver their baby [because] of what else is going on.”

With scheduled cesarean deliveries, there are fewer excuses for missing the opportunity to perform a patient’s requested salpingectomy, so Crofton’s research looked only at patients planning a vaginal delivery and who expressed the desire for a tubal procedure at prenatal care visits.⁴

In those cases, it should be likely that patients receive their desired method because if they are enrolled in Medicaid, they already would have received consent documentation to sign for the 30-day waiting period. But it still was a problem, and Crofton’s qualitative study identified some of the reasons women were denied salpingectomies they had requested.⁴

Investigators interviewed patients and their nursing, obstetric, and anesthesia teams, focusing on obstacles to patients obtaining requested postpartum permanent contraception. They found that healthcare workers’ personal values influenced their motivation to ensure these procedures are completed and that obstacles are similar for completed and noncompleted procedures. The difference often is a champion who optimizes interdisciplinary collaboration and advocates for care.⁴

It is difficult to determine precisely why some of these procedures were not completed if a researcher is only reviewing charts, Crofton says. “Chart reviews are dependent on documentation,” she explains. “Say a patient keeps their epidural in and 10 hours go by, and the unit is busy and hasn’t done the procedure, and then the patient says, ‘I want to eat and sleep and go home with my children, and I don’t want to do this.’ How do we document this?” The chart may show the patient changed her mind without providing additional information about how long the patient had to wait.

“In the places where I work, there are hardworking providers who try to do their best for patients, but when you’re working in labor and delivery and there is limited nursing staff, starting a procedure that isn’t emergent and will take time and resources from the unit may make someone else’s care become urgent,” Crofton explains. “We’re not just making these decisions independently but are thinking about justice for the whole unit.”

Any decisions to perform postpartum salpingectomy procedures should be based on safety to both the patient and the medical unit. But there are ways clinicians can improve access to the procedure for women who request it and are a good fit for it, Crofton says. If the team’s physician is not skilled at performing a salpingectomy, then they can call a colleague to proctor them and teach them the procedure.

“We do this in many other situations in our field,” she says. “For example, if I’m in the OR doing an oncology case and it becomes complicated, and I don’t have the skills to fix the bowel myself, I call a gynecologist, and they’ll come in and help with the procedure.”

The same culture of calling a colleague for help has not been used as much for postpartum tubal procedures, but there is no reason it could not be adopted, she adds. “If we evaluate this as a surgical skill and shift the culture to include that help, that could really shift our ability to complete them,” Crofton says.

The study’s findings show that clinicians can do more to make postpartum permanent contraception happen, partly by just thinking of this as a priority for the team if this is what the patient desires, she adds.

“I am thinking about this a lot and trying to make it happen,” Crofton says. “We need to counsel patients on the risks, benefits, alternatives, and details of surgical recovery,” she explains. “If we could make the system processes smoother, that would free up provider time and mental energy to do appropriate counseling.”

Here are Crofton’s suggestions for improving access to permanent contraception:

• Make protocols for plans to provide postpartum salpingectomy procedures, including plans for anesthesia.
• Assess whether patients are good candidates for the procedure and give them better education about why they are or are not a good candidate.
• Explain to patients the size of the incision and how much pain they might expect.
• Ask all team members, including the bedside nurse, charge nurse, anesthesia team, and OB/GYN to be on board with improving access. Everyone needs to work together to get these cases done.
• Have a planned huddle to discuss patients who want a postpartum permanent contraception procedure and determine when the team would have time to book an operating room to provide the procedure. “They can say, ‘We are really busy right now, but in two hours we can book an OR for this patient,’ or they can say, ‘She’s not an appropriate surgical candidate for these reasons, and we need to talk with her about our concerns,’ or they might say, ‘There is no way to do this today, but let’s fast-track her for an outpatient procedure,’” Crofton says.
• Have a checklist that the team could implement and document on the electronic medical record for patients who want a postpartum permanent contraception procedure, she says.
• Document if the patient has Medicaid and if the federal Medicaid form is signed and dated.
• If providers do not do these procedures themselves, they could refer patients to an appropriate specialist for preoperative consultation.

The study did not ask patients about which procedure they had for permanent contraception — tubal ligation or salpingectomy, she notes.

“In my personal practice, I try to do a complete salpingectomy when I’m doing postpartum permanent contraception procedures,” she adds.

Robert Hatcher, MD, MPH, Founding Author, Contraceptive Technology and Professor Emeritus of Gynecology and Obstetrics, Emory University School of Medicine in Atlanta, suggested that in the future two factors need to be kept in mind. First, every effort should be made to make complete salpingectomy available for women in the postpartum period as well as other times. Second, bilateral salpingectomy has no failures with greater protective effects against ovarian cancer than tubal ligation.

Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.

References

1. Schwartz AA, Sheikh Z. What is a salpingectomy (fallopian tube removal)? WebMD. March 20, 2024. https://www.webmd.com/women/what-is-a-salpingectomy

2. Zamorano AS, Mutch DG. Postpartum salpingectomy: A procedure whose time has come. Am J Obstet Gynecol. 2019;220(1):8-9.

3. Young M. Bilateral salpingectomy: The preferred method of permanent contraception. Clinician.com. May 1, 2025. https://www.clinician.com/articles/bilateral-salpingectomy-the-preferred-method-of-permanent-contraception

4. Crofton K, Johnston A, Kaszubinski S, et al. Postpartum permanent contraceptive procedures: A 360-degree qualitative investigation. Contraception. 2025;Oct 30:111281. [Online ahead of print].