OT notes · Obstetrics

Postpartum / interval minilap tubal ligation (Pomeroy)

Usual anaesthesia
Local infiltration with 1% lignocaine with IM/IV sedation-analgesia (recommended by the national sterilisation standards); spinal or GA only where full anaesthesia back-up exists
Position
Supine; slight Trendelenburg and lateral tilt to bring each tube into view
Setting
elective

Operative note template for postpartum or interval minilaparotomy tubal ligation by the modified Pomeroy method, with a filled example for a postpartum tubectomy on day 2 after vaginal delivery under local anaesthesia with sedation.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • failure of the operation with later pregnancy
  • the operation is permanent for all practical purposes
  • bleeding from the mesosalpinx, which may need a bigger incision
  • inability to find a tube, so sterilisation may be incomplete
  • bowel or bladder injury on entering the abdomen
  • wound infection
  • reaction to local anaesthetic or sedative drugs
  • regret later

Pre-operative details for this operation

  1. TimingPostpartum (within 7 days of delivery)Interval (6 weeks or more after delivery)With / within 7 days of surgical MTPdate and mode of delivery or LMP
  2. Eligibility checkedever married, age 22 to 49 years, at least one child over 1 year old, not sterilised before, Hb 7 g/dl or more
  3. Sterilisation consent (Annexure 1) signedYes, signed / thumb impression, witnessed
  4. Medical Record and Check List (Annexure 2) filled by operating surgeon before surgeryYes
  5. Hb, urine sugar and albuminpregnancy test for interval cases if needed
  6. Pelvic findingsuterine size and position, adnexa; rule out PID
  7. Nil by mouthno solids, milk or tea 6 h, no water 4 h
  8. Bladder emptiedVoidedCatheterised

Anaesthesia and position

  1. AnaesthesiaLocal with sedation-analgesiaLocal onlySpinalGeneraldrug, dose, route and time of each sedative; lignocaine strength and total volume (not over 3 mg/kg, maximum 200 mg)
  2. PositionSupineSupine with slight Trendelenburg (not over 20 degrees)
  3. Uterine elevator (interval cases)UsedNot used

Operative findings

  1. Uterusheight of fundus (postpartum), size, adhesions
  2. Right tubeidentified and followed to fimbria: yes / no; appearance
  3. Left tubeidentified and followed to fimbria: yes / no; appearance
  4. Ovariesnormal / cyst / other

Procedure (steps)

  1. Parts painted and drapedantiseptic used, applied twice
  2. Local infiltration1% lignocaine, volume, time; effect checked before incision
  3. Skin incisionInfraumbilical (postpartum)Suprapubic transverseSuprapubic verticallength in cm
  4. Sheath opened, recti separated, peritoneum opened
  5. Right tube deliveredmethod (finger sweep behind cornu, Babcock, tubal hook); fimbria seen
  6. Right tube occludedModified PomeroyParklandOthersite from cornu (cm), suture material and size, length of tube excised, lumen seen at both cut ends
  7. Left tube delivered and occludedsame details as right
  8. Haemostasis of both stumps checked before release
  9. Tube not found (if so)side, what was tried, client informed, entry countersigned by client

Closure, drains and dressing

  1. Peritoneum and sheathsuture material and size
  2. SkinInterrupted non-absorbableAbsorbable subcuticular
  3. DressingSmall dry dressing

Specimens and implants

  1. Tubal segmentsRight and left sent separately for HPENot sentlabel each side

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Vitalspulse, respiration, BP every 15 min for 1 hour, then hourly till 4 hours
  2. Dressingcheck for oozing
  3. Vaginal bleedinginterval cases: bleeding other than menses may mean vulsellum injury to cervix
  4. Oral intakewater, tea, juice when awake and comfortable
  5. Analgesicdrug, dose, frequency
  6. Discharge criteriaat least 4 hours after the procedure, vitals stable, fully awake, passed urine, can walk and drink
  7. Post Operative Instruction Card (Annexure 3)given, instructions explained in local language
  8. Stitch removal and follow-upfollow-up at 48 hours, day 7, and 1 month or after first period
  9. Resumption of intercoursepostpartum: after 2 weeks; interval: after 1 week
  10. Sterilisation certificate (Annexure 4)issued 1 month after surgery or after first period, whichever is earlier

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mrs. S.D., 27 years, P2L2 (children 4 years and 2 days), day 2 after normal vaginal delivery, requests permanent sterilisation. Weight 48 kg.

Case details

Date: 09/05/2026. Elective postpartum tubectomy (day 2 after delivery). Minor OT.

Start 11:10. End 11:40.

Surgeon: Dr A. (2nd-year resident, OBGY). Assistant: Dr B. Consultant: Dr C., available in OT complex. Staff nurse: Sr E.

Indication and pre-op

Family complete. Eligibility checked: ever married, 27 years, has a living child above 1 year of age (4 years), no previous sterilisation of either partner.

Application cum consent form for sterilisation (Annexure 1) signed by client in the presence of witness, explained in Marathi. Medical Record and Check List (Annexure 2) filled before surgery.

Hb 10.2 g/dl. Urine sugar and albumin nil. Uterus 18 weeks size, well contracted. Lochia normal. Afebrile.

Nil by mouth 6 hours. Voided urine before OT. WHO checklist done.

Anaesthesia and position

Inj pethidine 37.5 mg + inj promethazine 12.5 mg IM at 10:35. Local infiltration with 1% lignocaine 10 ml (100 mg) at 11:08, effect checked.

Supine. Parts painted twice with povidone-iodine and draped.

Procedure

Fundus 2 fingers below umbilicus. 3 cm infraumbilical transverse skin incision. Sheath opened, recti separated, peritoneum opened.

Right tube: fingers swept behind right cornu, tube lifted with Babcock at mid-isthmus, followed to fimbria. Loop made 2.5 cm from cornu and tied at the base with chromic catgut 1-0, square knot. 1 cm of tube excised above the tie. Lumen seen at both cut ends. No bleeding. Ends allowed to retract.

Left tube: same method. Loop 2.5 cm from cornu, chromic catgut 1-0, 1 cm excised, lumen seen at both ends, no bleeding.

Both ovaries normal.

Closure

Peritoneum and sheath closed with absorbable suture. Skin closed with 2 interrupted non-absorbable sutures. Small dry dressing.

Specimens and implants

Right and left tubal segments sent for HPE in separate labelled containers.

End of procedure

Estimated blood loss 15 ml. No complications.

Mop, needle and instrument count correct.

Pulse 84/min, BP 110/70 mmHg, awake and talking at end. Shifted to postnatal ward.

Post-op orders

Pulse, respiration, BP every 15 min for 1 hour, then hourly for 4 hours.

Oral fluids when fully awake. Breastfeeding to continue.

Oral analgesic as prescribed.

Post Operative Instruction Card (Annexure 3) given and explained in Marathi. Follow-up at 48 hours, day 7 (stitch removal) and 1 month.

Sterilisation certificate (Annexure 4) at 1 month or after first period.

Signature

Dr A., JR-2, OBGY. Reg. no. ________. 09/05/2026, 11:55.

Must document for this operation

  • Each tube identified by following it to the fimbria, side by side. Seeing the fimbria is how the tube is proved to be the tube, and any later failure inquiry will look for this line.
  • Method, suture, site from the cornu and length of tube removed on each side. The next surgeon needs this for a reversal or for a failed sterilisation workup.
  • If a tube could not be found or ligated, write it, tell the client, and get her countersignature. The national standard requires this; without it no certificate should be issued and the failure is not covered by the indemnity scheme.
  • Sedative and local anaesthetic drugs with dose, route and time. Sterilisation deaths are audited, and drug overdose or toxicity is looked at first.
  • Timing (postpartum, interval, post-MTP) and approach (minilap). These are fields in the Annexure 2 medical record and decide whether a laparoscopic method was allowed.
  • Tubal segments sent for HPE, labelled by side. Histology proving tube on both sides is the best evidence if a pregnancy occurs later.

Common mistakes in these notes

  • Writing 'bilateral TL done' with no method, suture or length excised.
  • Not recording that the fimbria was seen on each side.
  • Filling the Annexure 2 checklist after the operation instead of before it.
  • Leaving out the sedation drugs and timing.
  • Not recording a failed or one-sided ligation, or not taking the client's countersignature for it.

Indian practice and paperwork

  • The client signs the 'Application cum consent form for Sterilization Operation' (Annexure 1) before surgery. It records that the operation is permanent, may fail, and that she will report within two weeks of a missed period. (MoHFW Standards & Quality Assurance in Sterilization Services, Nov 2014, section 2.2 and Annexure 1: https://nhm.gov.in/images/pdf/programmes/family-planing/guidelines/Standards_and_Quality_Assurance.pdf)
  • The operating surgeon must fill the 'Medical Record & Check List for Female and Male Sterilization' (Annexure 2) before starting surgery. (SQAS 2014, section 2.2 and Annexure 2 (URL above))
  • Eligibility: ever married, female age above 22 and below 49 years, at least one child above one year of age, neither partner sterilised before. Clients with Hb below 7 g/dl are not accepted. (SQAS 2014, sections 1.3.1 to 1.3.5 and 2.2 (URL above))
  • Only minilap tubectomy is done within 7 days of childbirth. Laparoscopic occlusion is not done in the early postpartum period up to 42 days. (SQAS 2014, section 2.2 (URL above))
  • Local anaesthesia is recommended for minilap. 1% lignocaine without adrenaline, usually 10 ml, never over 3 mg/kg body weight and never over 200 mg (20 ml of 1%) in total. Sedation by weight, e.g. 40 to 50 kg: pethidine 37.5 mg with promethazine 12.5 mg IM 30 to 45 min before surgery. (SQAS 2014, section 2.5 and Table A (URL above))
  • Technique standard: follow each tube to the fimbria, occlude within 2 to 3 cm of the cornu in the isthmus, excise 1 cm, no cautery or crushing, modified Pomeroy with a square knot of 1-0 chromic catgut. (SQAS 2014, section 2.7 (URL above))
  • Post Operative Instruction Card (Annexure 3) at discharge in the local language. Sterilization Certificate (Annexure 4) one month after surgery or after the first period, whichever is earlier. (SQAS 2014, sections 2.8 to 2.10 (URL above))
  • If a tube could not be identified and ligated, document it on the case sheet, inform the client, and have the entry countersigned (or thumb impression). No certificate is issued, and the case is not eligible for failure compensation under FPIS. (SQAS 2014, section 2.10 (URL above))

Sources

  • Te Linde's Operative Gynecology. 13th ed. Wolters Kluwer; 2024, Ch 18, Tubal sterilization, e-book PDF pp. 919-930, 949-951.
  • Apuzzio JJ, Vintzileos AM, Berghella V, Alvarez-Perez JR, eds. Operative Obstetrics. 4th ed. CRC Press; 2017, Ch 29, Wound healing, sutures, knots, needles, drains, and instruments (Bilinski RT, Alvarez-Perez JR): catgut for tubal ligation, pp. 387.
  • Ministry of Health and Family Welfare, Family Planning Division. Standards & Quality Assurance in Sterilization Services. November 2014. Sections 1.3, 2.2, 2.5 (Table A), 2.6, 2.7, 2.8, 2.9, 2.10; Annexures 1-4. nhm.gov.in/images/pdf/programmes/family-planing/guidelines/Standards_and_Quality_Assurance.pdf

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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