Cervical cerclage (McDonald / Shirodkar)

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

• rupture of membranes
• infection of the membranes (chorioamnionitis)
• miscarriage or preterm labour after the procedure
• bleeding
• cervical tear, especially if labour starts with the stitch in place
• stitch displacement or failure
• bladder injury (Shirodkar)
• need to remove the stitch in theatre

Pre-operative details for this operation

1. IndicationHistory-indicatedUltrasound-indicatedExamination-indicated (emergency / rescue)history: number and weeks of previous second-trimester losses / preterm births; ultrasound: cervical length in mm on TVS (transvaginal scan) and date
2. Gestational age todayby dating scan
3. Ultrasound before cerclagelive fetus, normal anatomy as far as gestation allows, placenta site
4. Contraindications excludedno bleeding, no contractions, membranes intact, no signs of infection, no lethal fetal anomaly
5. Infection screen / amniocentesisNot neededVaginal swabAmniocentesis doneconsider amniocentesis before examination-indicated cerclage
6. Cervix on speculum / digital examinationos closed / dilated (cm), membranes seen at or beyond os
7. Consentinclude plan for removal at 36 to 37 weeks and earlier if labour or leaking

Anaesthesia and position

1. AnaesthesiaSpinalGeneral
2. PositionDorsal lithotomyLithotomy with head-down tilt (bulging membranes)
3. Exposureweighted speculum, right-angle retractors, sponge-holding forceps on the cervix

Operative findings

1. Cervixlength of vaginal portion, consistency, os closed / dilated (cm), any old tear
2. MembranesNot visibleVisible at internal osBulging to or beyond external os
3. Vaginal dischargeNormalAbnormal (describe)

Procedure (steps)

1. Painting and drapinggentle vaginal preparation if membranes are bulging
2. BladderEmptied with catheterFoley in situFilled retrograde (to reduce membranes)
3. Cervix heldsponge-holding forceps / tenacula, number
4. TechniqueMcDonaldShirodkarOther
5. Suture materiale.g. Mersilene tape, Prolene, needle type
6. McDonald: purse-stringlevel (just below the bladder reflection), number of bites (4 to 6), placed high posteriorly, uterine vessels avoided at 3 and 9 o'clock, bites into stroma but not into canal
7. Shirodkar: dissectionanterior transverse incision at bladder reflection, bladder pushed up; posterior incision; tape passed submucosally above cardinal ligaments; mucosa closed or not
8. Membrane reduction (if bulging)method: head-down tilt, bladder filling, Foley balloon, sponge on a stick, amnioreduction
9. Knotsite (anterior / posterior), number of throws, length of ends left (2 to 3 cm) for removal
10. Tightnessinternal os closed, fingertip only at external os
11. Number of stitchesOneTwo

Closure, drains and dressing

1. Bleeding at suture sitesNoneControlled with pressureExtra stitch
2. Membranes intact at end, no liquor leak
3. Vaginal packNonePack left: remove at (time)
4. Fetal heart after procedureby Doppler or ultrasound

Specimens and implants

1. Cerclage suturematerial, size / width, make, lot number: it stays in until removal
2. Amniotic fluid / vaginal swab sentNot applicableSent for culture

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. Observationspulse, BP, temperature; watch for pain, bleeding, leaking or contractions
2. Fetal heartcheck before discharge
3. Medicinesantibiotic or tocolytic only if ordered, with drug, dose and duration; progesterone to stop or continue as per plan
4. Dischargeusually same or next day; no bed rest needed
5. Warning signscome back at once with pain, bleeding, leaking fluid or fever
6. Follow-up scancervical length on TVS as planned
7. Removal planat 36 to 37 weeks, or earlier with labour or rupture of membranes; write the date on the card

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