# Situation: At the family planning clinic of a district hospital, the nurse counsels women and couples who want to space their children or have completed their families. A 36-year-old para 4 gave birth vaginally 10 days ago without complications and asks for bilateral tubal ligation (BTL). Which points should the nurse include in her counseling? 1. The procedure is meant to be permanent 2. It protects against pregnancy right after the procedure 3. It can be done now, while she is still within 6 weeks of birth 4. It should be scheduled once she is at least 6 weeks after birth

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629589  
> language: ko  
> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: At the family planning clinic of a district hospital, the nurse counsels women and couples who want to space their children or have completed their families.

A 36-year-old para 4 gave birth vaginally 10 days ago without complications and asks for bilateral tubal ligation (BTL). Which points should the nurse include in her counseling?
1. The procedure is meant to be permanent
2. It protects against pregnancy right after the procedure
3. It can be done now, while she is still within 6 weeks of birth
4. It should be scheduled once she is at least 6 weeks after birth

## 보기

1. 1 and 4
2. 1, 2 and 3
3. 1 and 3
4. 1, 2 and 4 **✔ 정답**

**정답: 4**

## 해설

Tubal ligation is intended to be permanent and, unlike vasectomy, is effective immediately. Under the WHO medical eligibility criteria, postpartum female sterilization is acceptable within 7 days of birth, should be delayed from 7 days to less than 42 days, and is acceptable again from 42 days (6 weeks). At 10 days postpartum, she should be scheduled at 6 weeks or later.

## 심화 해설

Core counseling points for BTL at 10 days postpartum

The correct combination is 1, 2, and 4. Bilateral tubal ligation is designed as a permanent method of contraception, and it provides immediate protection against pregnancy because the fallopian tubes are physically interrupted at the time of surgery. However, at 10 days after vaginal delivery, the client falls within the interval in which the World Health Organization advises delaying the procedure until at least 42 days postpartum.

The WHO medical eligibility framework divides the postpartum period into three windows for female sterilization: acceptable within the first 7 days, a cautionary delay from 7 days to less than 42 days, and acceptable again from 42 days onward. Because this client is at day 10, she is in the middle window, so scheduling her for 6 weeks or later is the appropriate plan. The statement that it “can be done now” is therefore incorrect.

| Postpartum timing | WHO acceptability for BTL | Clinical implication |
| --- | --- | --- |
| Within 7 days of birth | Acceptable | Can be performed before discharge if consent was obtained antenatally |
| 7 to less than 42 days | Delay recommended | Increased technical difficulty; uterine involution still ongoing; higher risk of complications |
| 42 days (6 weeks) or later | Acceptable again | Uterus has returned to near nonpregnant size; safer surgical window |

Key point! Do not confuse the timing rule for BTL with the fact that the method itself is effective immediately once performed. The 10-day delay is about surgical safety and technical feasibility, not about contraceptive efficacy.

Unlike vasectomy, which requires a waiting period and confirmatory semen analysis before it is considered reliable, tubal ligation interrupts the fallopian tubes at the time of surgery and therefore protects against pregnancy right away. This distinction is frequently tested and explains why statement 2 is correct even though the procedure is being scheduled for a later date.

The rationale for delaying BTL between 7 and 42 days postpartum relates to the physiologic changes of the puerperium. During this period, the uterus is still undergoing involution, vascularity is increased, and the fallopian tubes are more edematous and friable, which can make the procedure technically more challenging and increase the risk of bleeding or injury to surrounding structures. Watch out! If a client presents during this window and desires permanent contraception, the nurse should counsel her to use a temporary method—such as condoms or progestin-only options if appropriate—until the BTL can be safely performed at 6 weeks or later.

In the immediate postpartum setting, some centers now offer long-acting reversible contraception (LARC), such as postpartum intrauterine devices or implants, as an alternative or bridge for clients who desire permanent contraception but cannot receive BTL within the first 7 days. This aligns with quality improvement efforts to increase access to immediate postpartum family planning and reduce unintended or closely spaced pregnancies. However, for this client who specifically requests BTL, the counseling must emphasize that the method is permanent, that it works immediately once placed, and that the timing must be adjusted to the safe window at 6 weeks postpartum or beyond.

## 임상 시나리오

Postpartum BTL Counseling: Timing and EffectivenessApplying WHO MEC to a 10-Day Postpartum Client
Bilateral tubal ligation is a permanent method of contraception and is effective immediately after the procedure because the fallopian tubes are physically interrupted.

For postpartum clients, the WHO medical eligibility criteria define three windows: acceptable within 7 days of birth, delay recommended from 7 to less than 42 days, and acceptable again from 42 days (6 weeks) onward.

CautionAt 10 days postpartum, the client is in the delay window due to ongoing uterine involution and increased technical difficulty. Schedule the procedure for 6 weeks or later, but do not confuse this timing delay with the method's immediate effectiveness once performed.

## 핵심 개념

- **Bilateral Tubal Ligation (BTL)** — A permanent surgical method of female sterilization that involves interrupting the fallopian tubes to prevent pregnancy.
- **WHO Medical Eligibility Criteria (MEC)** — A framework that provides guidance on the safety and timing of contraceptive methods based on clinical conditions and timing.
- **Postpartum Sterilization Timing** — For female sterilization, the procedure is acceptable within 7 days of birth, delayed from 7 to less than 42 days, and acceptable again from 42 days onward.
- **Uterine Involution** — The process by which the uterus returns to its nonpregnant size and condition after childbirth, typically completed by 6 weeks postpartum.
- **Immediate Contraceptive Effectiveness** — A characteristic of BTL where pregnancy protection begins right after the procedure because the fallopian tubes are physically blocked.

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