[...]

[Upbeat music]

[Washington University, Obstetrics, Gynecology seal]

[Music]

[Hospital exterior inscription 'Maternity']

[Obstetrics, Labor 1-11, Delivery 1-9, Admitting]

[Obstetrics, no admittance]

[Labor]

[Delivery]

[Nurse 1:] Pregnancy.

[Nurse Judy Gamblin:] Labor.

[Nurse 2:] Delivery.

[Nurse 1:] But wehave another choice.

[Nurse 2:] A permanent choice?

[Judy Gamblin:] Yes.

My husband and Ihave discussed this,

and we have agreed that I shouldtake a quick step to stop.

[Music]

[Dr. Friedrich:] A quick step tostop conception permanently

by outpatienttubal sterilization

through a laparoscope underlocal or general anesthesia.

[Judy Gamblin:] Hi.

I'm Judy Gamblin.

I have an appointmentto see Dr. Friedrich.

[Office background music]

[Receptionist:] Dr. Friedrich,this is Judy Gamblin.

[Dr. Friedrich:] Oh, Judy, we don't really

need any introduction.

We have known each other formany years and worked together.

Would you come inand take your seat?

And I'll take your history.

We will have to go throughthe complete history

and physical examination beforewe can decide whether surgery

can be done or not.

[Judy Gamblin:] OK.

[Dr. Friedrich:] All we have todo is a pelvic examination,

and then we'll be donewith the examination, Judy.

OK?

[Judy Gamblin:] OK.

[Dr. Friedrich:] You knowthat the operation can also

be done on husbands,and I assume

that you and your husband havediscussed that and that you

have decided that you would havethe sterilization done and not

your husband.

Is that correct?

[Judy Gamblin:] That's true.

[Dr. Friedrich:] Now, you haveseen these operations before,

and I really wouldn't have togo through all the details.

But I think it's well anywayto go through the procedure

in a step-by-step fashion.

[Music ends]

Let us first look at thenormal female pelvic organs.

[Judy Gamblin:] The vagina.

The cervix.

The uterus.

The two tubes and ovaries.

[Dr. Friedrich:] And nextwe will discuss the events

that may lead to pregnancy.

[Judy Gamblin:] If an egg is ovulatedand migrates into the Fallopian

tube...

[Dr. Friedrich:] Andmale spermatozoa

migrate from the vaginathrough the cervix and uterus

into the tube...

[Judy Gamblin:] fertilization and pregnancy may result.

[Dr. Friedrich:] Fertilizationcan be prevented permanently

by tubal sterilization

[Judy Gamblin:] Blocking thepassage for both semen and egg

by either:

[Dr. Friedrich:] Ligation

[Judy Gamblin:] Tying stringsaround the tubes.

[Dr. Friedrich:] Coagulation

[Judy Gamblin:] Heating or burning.

[Dr. Friedrich:] Excision

[Judy Gamblin:] Cutting andremoving a piece of the tube.

[Dr. Friedrich:] Obstruction.

[Judy Gamblin:] By applyingmetal or plastic

clips or a silasticrubber ring to each tube.

Menstruation, normalovarian function,

and sexual activities

[Dr. Friedrich:] are not affectedby tubal sterilization.

Ovulated eggs are rapidlyabsorbed by your body.

Tubal sterilizationcan be accomplished

with a laparoscope, which isa modern optical and surgical

instrument that can be loadedwith a small silastic rubber ring,

a little over one eighth of an inch,

or about 4 millimetersin diameter

[Judy Gamblin:] Whichis about one half

of the diameter of thehole in a Life Saver.

[Dr. Friedrich:] The ringis stretched on a cone

and applied to the tipof a special forceps

in the laparoscope before itis introduced into the abdomen.

Since there is no spacenor light in the abdomen

and pelvis to work in, theymust be insufflated temporarily

with one to threequarts or liters

of a natural gas suchas carbon dioxide--

[Judy Gamblin:] Which isin the air we breathe.

[Dr. Friedrich:] Thena small incision

is made just belowthe umbilicus.

[Judy Gamblin:] And thelaparoscope is introduced.

[Dr. Friedrich:] The Fallopiantube is identified and grasped,

and [Inaudible] tube ispulled inside the instrument,

and the ring is released.

[Judy Gamblin:] Blockingthe tube permanently.

[Dr. Friedrich:] So you cannotchange your mind after it has

been done.

This would requiremajor surgery.

I also should tell youthat with all methods

of total sterilization, there'sa slight chance of a pregnancy.

It is about 1 out of1,000, no matter which way

we do the procedure.

This compares favorablywith three pregnancies

per year in 1,000 womenon birth control pills

and 80 pregnanciesin 100 women who

do not use any contraceptives.

You have to realizethat whenever

we use some stitches inyour skin or in your body,

this is just atemporary measure.

Eventually, over a numberof weeks or months,

the stitches will bereplaced by scar tissue that

is formed by your own body.

And it is scar tissue thatkeeps your tubes closed,

and it is scar tissue thatkeeps your skin in your abdomen

[? together. ?] As in anymedical treatment or surgery,

complications may also occurwith tubal sterilization.

[Judy Gamblin:] Drug allergies.

[Dr. Friedrich:] If youhave been sensitive

to particularmedications in the past,

we will avoid theseand similar ones

or test you before surgery.

[Judy Gamblin:] Anesthesia.

[Dr. Friedrich:] Seriousreactions to local anesthesia

are extremely rare.

With general anesthesia, analert, competent anesthetist

can usually preventcomplications or recognize

and treat them immediately.

[Judy Gamblin:] Instruments.

[Dr. Friedrich:] Anysharp, or rigid,

or hot instrumentcould accidentally

injure bowel, bladder, andureters or blood vessels.

The danger of injuryis greater if you

have had abdominal,or pelvic surgery,

or infections in the past.

Now, since there is alwaysa slight possibility

that a complicationmay occur, you

will have to sign someoperative permit

for major procedures.

[Judy Gamblin:] Infection.

[Dr. Friedrich:] Infectionof the incision

is extremely rare withproper antiseptic preparation

before surgery.

[Office background music]

An old pelvic infectionmay occasionally

be reactivated by a tubalsterilization operation.

But I can assure you thatcomplications are very rare.

Now Debbie will haveyour blood drawn for tests,

have you and your husbandsign all necessary papers,

and schedule you for surgery.

And remember that youare free to change

your mind before surgery.

Please continue your presentmethod of birth control,

and on the day of surgery,after midnight do not

eat, drink, or smoke.

[Silence]

[Judy is led into surgical suite]

[Footsteps]

[Dr. Friedrich:] Good morning, Judy.

I see you're just ascheerful as you always are.

You must have had agood night's rest.

Now we have to give youan IV started in your arm.

One thing that mostpeople don't like.

Don't let that bother you.

Now, you let me know if youfeel any stinging or any pain

in your arm, andyou also tell me

if it looks as if the ceilingor the lights are moving.

And then we willmix our cocktail

inside your blood vessels.

[Judy Gamblin:] [Inaudible].

[Dr. Friedrich:] First, someValium, and then some Demerol.

[Judy Gamblin:] Oh, Ifeel it in my head.

I feel it.

[Dr. Friedrich:] Youfeel it in your head?

And now we turnthe drip down.

Judy, now I'll go and scrubmy hands, and in a few minutes

I'll be back, and thenwe'll start the operation.

OK.

Now we're going to prep you.

We have some warm solution.

Warm Betadine solution, andthat should be quite comfortable

right there.

[Judy Gamblin:] Oh, that was super [?]

[Interposing voices]

[Dr. Friedrich:] little needlestick in your belly button

and give you the localinfiltration there,

and that will make it numb.

[Judy Gamblin:] Mhm.

[Machine pulsing noise]

[Dr. Friedrich:] OK, Judy.

We're going to put an instrumentinside the mouth of your womb

now so that we can lift upthe womb and expose the tubes.

[...]

All right, Judy.

Now we will have toattach some tubes

and then put the needleinside your belly button,

and put some gas inside you.

You might feel my pinch.

[...]

Now we have to runsome tests to make sure

that we're in the proper spot.

[...]

[Judy Gamblin:]It's fantastic.

You don't even feel that at all.

[Dr. Friedrich:] OK, nowwe turn the gas on.

[...]

Everything isflowing very nicely.

And now, we will haveto turn your head down.

And you can have a pillowunderneath your head.

Now Judy, I thinkwe have enough gas.

We have to make a littleincision in the belly button.

[Machine noise]

Then we have to put aninstrument inside you.

You will feel a lot of pressure.

But that will beover in a moment.

[...]

We are going to put theinstrument inside you.

[Metal connector click]

And now we turn the teaching attachment on,

so that you can havea look inside you.

[Fan motor spinning up]

And the ring isattached already.

And I'm going to introduce it.

[...]

Now would you like tohave a look, Judy?

[Judy Gamblin:] Yes.

[Surgical assistant:] [Inaudible]

[Dr. Friedrich:] Now can you see 

the uterus? I find a little fibroid tumor in it.

[Interposing voices]

[Images from the laproscope]

[Dr. Friedrich:] That's your tube,your ovary on the right side,

blood vessel...

Now we go to the other side ofthe tube, the ovary behind it.

And [?]

[...]

Now if Claire can holdthe instrument

for me, I willpick up the tube.

[Machine noise]

Identify it.

And then I will attach one ring.

Now this will be a littleuncomfortable for a moment.

The tube is a little wider.

[...]

OK, now this is it on one side.

[...]

[Suction sound]

[...]

OK, Judy, you have a little [?] there.

[...]

[Suction sound]

[...]

A small fiber tube [?] the uterus.

Now this was one tube.

And we'll startwith the next one.

And in a moment,we'll be all done.

[Machine sound]

Now that's it.

Both tubes have been tiedwith Silastic rubber rings.

This is the left side.

There is a small myoma.  Anothersmall myoma.  And the right tube.

The ovarian tube.

[...]

And there is your appendix.

There, we are coming tothe tip of the appendix.

Can you see it?

Now we will removethe instruments.

[Machine noise]

Now we will releasethe gas again.

[...]

And now, we have to put a fewstitches underneath your skin.

And the wholething will be done.

I'll clean it up a little bit.

We don't even haveto put a Band-Aid on.

[Judy Gamblin:] Thank you.

[Dr. Friedrich:]Thank you very much.

You were an excellent patient.

From your experience, youwould think that almost anyone

could go through this.

[Judy Gamblin:] Oh,certainly, sure.

[Dr. Friedrich:] When youfeel ready to go home,

remember that youhad potent drugs.

Have been escort take you home.

You may eat, drink, batheor shower, and work.

Continue your presentmethod of birth control

until your nextmenstrual period.

And call if you have questions.

[Judy Gamblin:] And I'mready for my tea now.

[Dr. Friedrich:] You ready?

[Judy Gamblin:] I'm ready.

[Upbeat music]

[Department of Obstetrics and Gynecology]

[Washington University School of Medicine]

St. Louis, Missouri; 1970

[Surgeon and director; Ernst. R. Friedrich, M.D.]

[Head nurse, counselor and patient; Judy Gamblin, R.N.]

[Artwork and animation; Elise Csapo, Gabriele Salau]

[Camera; Brian Hayden]

[Editor; Andrew Todd]

[In production; Salma Saifee, M.D., Lora Bell, R.N., Carolyn Smith, L.P.N., Debbie Candice]

[Sponsored by; United States Department of State, Agency for International Development]

[Music]

[...]