OT notes · Obstetrics

Lower segment caesarean section (LSCS)

Usual anaesthesia
Spinal (subarachnoid block)
Position
Supine with left lateral tilt
Setting
emergency

Operative note template for a primary lower segment caesarean section, with a filled example for an emergency LSCS done for fetal distress under spinal anaesthesia.

Download printable PDFFree. Just log in with your Google (Gmail) account.

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

  • bleeding and blood transfusion
  • extension of uterine incision
  • bladder, bowel or ureteric injury
  • wound infection
  • thromboembolism
  • hysterectomy if bleeding cannot be controlled
  • scar rupture and placenta accreta in future pregnancy
  • fetal laceration

Pre-operative details for this operation

  1. Indication for caesareanstate the actual reason, not just 'fetal distress': e.g. FHR pattern and duration
  2. Urgency category12341 = immediate threat to life of mother or fetus
  3. Robson group1 to 10
  4. Gestational age / parity / previous scars
  5. Time of decision for caesarean
  6. Blood grouped and cross-matchedgroup, Rh, units reserved
  7. Bladder catheterisedYes
  8. Anti-D / Rh statusRh positiveRh negative: plan for anti-D
  9. Consent for tubal ligation (if requested)Taken, separate formNot requested

Anaesthesia and position

  1. AnaesthesiaSpinalEpidural top-upCombined spinal-epiduralGeneralif GA, reason
  2. PositionSupine with left lateral tilt

Operative findings

  1. Lower uterine segmentWell formedPoorly formedThinned out
  2. LiquorClearMeconium stained (thin/thick)Blood stainedScanty
  3. Presentation and position at delivery
  4. Placentasite, delivered complete / incomplete, adherent areas
  5. Uterus, tubes and ovariesnormal / fibroids / adhesions / other
  6. Babylive / stillborn, sex, time of birth, weight, APGAR at 1 and 5 min, handed to paediatrician

Procedure (steps)

  1. Skin preparation and drapingantiseptic used
  2. Skin incisionPfannenstielJoel-CohenMidline verticallength
  3. Rectus sheath and peritoneum opened
  4. Uterovesical fold opened, bladder pushed downYesNot done
  5. Uterine incisionLow transverseLow verticalClassicalInverted T / J extension
  6. Delivery of babyvertex / breech / assisted with Wrigley's forceps / fundal pressure
  7. Cord clampingdelayed (time) or immediate (reason)
  8. Uterotonicdrug, dose, route, time
  9. Placenta and membranes deliveredControlled cord tractionManual removal
  10. Uterine cavity checked, cervical os patency confirmed
  11. Uterine closurenumber of layers, suture material and size, technique
  12. Haemostasisangles, extra sutures, any additional measures
  13. Tubal ligation (if consented)method, both tubes, portions sent
  14. Peritoneal toilet, tubes and ovaries inspected

Closure, drains and dressing

  1. Parietal peritoneumClosedNot closed
  2. Rectus sheathsuture material and technique
  3. Subcutaneous tissueclosed if fat > 2 cm
  4. SkinSubcuticularInterruptedStaples
  5. DrainNoneSubrectusIntraperitoneal
  6. Uterine tone and vaginal bleeding at end
  7. Urine in cathetercolour, haematuria?

Specimens and implants

  1. Placenta sent for HPEYesNoindication
  2. Tubal segments sent for HPEYesNot applicable
  3. Cord blood samplefor grouping / Coombs / gas

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. Vitals, uterine tone and bleedingevery 15 min for the first hour, then half-hourly till stable
  2. Uterotonic infusionif ordered: drug, dose, duration
  3. IV fluidstype and rate
  4. Analgesiadrug, dose, frequency
  5. Oral intakesips / liquids / soft diet from when
  6. Catheter removaltime
  7. Thromboprophylaxisearly mobilisation, stockings, LMWH if risk factors
  8. Breastfeedingstart within the first hour
  9. Anti-Dif mother Rh negative and baby Rh positive, within 72 h
  10. InvestigationsHb on day 1, others

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. R.S., 24 years, G1P0 at 39+2 weeks, in spontaneous labour at 6 cm with persistent late decelerations for 20 minutes despite intrauterine resuscitation.

Case details

Date: 12/03/2026. Emergency LSCS. OT 2.

Decision time 02:10. In OT 02:22. Spinal given 02:26. Skin incision 02:34. Baby delivered 02:38. Closure completed 03:15.

Surgeon: Dr A. (2nd-year resident, OBGY). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: non-reassuring fetal status. Late decelerations with every contraction for 20 min, baseline 160 bpm, reduced variability, not corrected by left lateral position, IV fluids and stopping oxytocin.

Urgency category 1. Robson group 1 (nullipara, single cephalic, 37 weeks or more, spontaneous labour).

Blood group B positive, 2 units cross-matched. Foley catheter in situ, urine clear.

Consent: general, procedure-specific and anaesthesia consent taken in Hindi from patient, husband as witness. No request for tubal ligation.

WHO checklist sign in and time out done. Inj cefazolin 2 g IV at 02:28, before skin incision.

Anaesthesia and position

Spinal anaesthesia. Supine with left lateral tilt. Parts painted with chlorhexidine-alcohol and draped.

Procedure

Pfannenstiel incision of about 12 cm. Rectus sheath opened transversely, recti separated, peritoneum opened vertically.

Uterovesical fold opened and bladder pushed down.

Lower segment well formed. Low transverse uterine incision, extended bluntly in a lateral and upward direction.

Liquor thin meconium stained.

Baby delivered as vertex, left occipito-transverse, with gentle fundal pressure. Live female, born 02:38, weight 2.9 kg, cried immediately, APGAR 7 and 9 at 1 and 5 min. Cord clamped at 1 min. Baby handed to paediatrician.

Inj oxytocin 5 IU slow IV over 1 to 2 minutes after delivery of the baby, followed by oxytocin 20 IU in 1000 ml RL infusion at 150 ml/h.

Placenta posterior upper segment, delivered by controlled cord traction, complete with membranes.

Uterine cavity wiped with a mop. Os patency confirmed from above.

Uterus closed in two layers with continuous polyglactin 910 (Vicryl) No. 1: first layer locking, second layer imbricating. Angles secured separately.

Haemostasis secured. Both tubes and ovaries normal. Peritoneal toilet done.

Closure

Parietal peritoneum not closed. Rectus sheath closed with continuous Vicryl No. 1. Subcutaneous fat 1.5 cm, not sutured. Skin closed with subcuticular Monocryl 3-0. No drain.

Uterus well contracted at end. Minimal vaginal bleeding. Urine clear, about 100 ml.

End of procedure

Estimated blood loss 600 ml (suction 350 ml + mops). No transfusion.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Specimens: none. Placenta not sent for HPE. Cord blood sent for grouping.

Patient shifted to post-operative ward in stable condition. Pulse 88/min, BP 118/72 mmHg.

Post-op orders

Pulse, BP, uterine tone and PV bleeding every 15 min for 1 hour, then every 30 min for 4 hours.

Oxytocin infusion as above to complete.

IV RL 1 L over 8 hours. Sips of water after 4 hours if no nausea, then liquids.

Inj paracetamol 1 g IV 8-hourly; inj diclofenac 75 mg IM 12-hourly if no contraindication.

Catheter removal when mobile, and not before 12 hours after the spinal.

Early mobilisation from 6 hours. Breastfeeding started in recovery.

Hb on post-op day 1.

Signature

Dr A., JR-2, OBGY. Reg. no. ________. 12/03/2026, 03:30.

Must document for this operation

  • The real indication, with the evidence for it. 'Fetal distress' alone does not stand in an audit or in court. Write the CTG pattern, its duration and what was tried first.
  • Decision time and delivery time. The decision-to-delivery interval is audited for category 1 caesareans. The usual target is within 30 minutes.
  • Type of uterine incision and any extension. This decides whether she can be offered a trial of labour in the next pregnancy. A classical or inverted T incision is a contraindication.
  • Number of layers and suture used for the uterus. The next obstetrician needs this when counselling about VBAC.
  • Baby details: time of birth, sex, weight, APGAR, condition. These also go into the birth register and the birth certificate.
  • Uterotonic drug, dose and time. Needed if she bleeds later and for PPH audits.
  • Tubes and ovaries seen and their appearance. An adnexal mass found at caesarean must be recorded and followed up.

Common mistakes in these notes

  • Writing 'fetal distress' with no CTG description.
  • Writing 'LSCS done' with no uterine incision type.
  • Recording the time of writing the note instead of the actual times of decision and delivery.
  • Leaving out the EBL, or writing 'minimal' for a caesarean.
  • Forgetting to note that a tubal ligation was done under separate consent.

Indian practice and paperwork

  • Under AB PM-JAY (HBP 2022) caesarean delivery is package SO057A. For a claim, the note must show the procedure, the anaesthesia type and the surgeon's registration number, and match what was booked. (NHA HBP 2022 / HBP 2.2 guidelines)
  • The placenta counts as human anatomical waste. If it is not sent for HPE, it goes in the yellow bag. Discarded formalin from specimen jars is chemical waste in the yellow (f) category. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)
  • NABH expects the operative note to be written before the patient is moved out of recovery, and the post-op care to follow a written plan. (NABH 5th ed., COP.14(e) and (f))
  • If a tubal ligation is added, it needs its own consent. An extra procedure without consent is defensible only when it was needed to save life or health (Samira Kohli v. Dr Prabha Manchanda, Supreme Court, 2008). ((2008) 2 SCC 1)

Sources

  • Apuzzio JJ, Vintzileos AM, Berghella V, Alvarez-Perez JR, eds. Operative Obstetrics. 4th ed. CRC Press; 2017, Ch 30, Cesarean delivery (Guirguis GF, Apuzzio JJ), pp. 393-414.
  • NICE guideline NG192. Caesarean birth (2021, updated 2024). Recommendations 1.4.3 (category 1 within 30 min), 1.4.30 (blunt extension), 1.4.39 (subcutaneous closure only if fat > 2 cm), 1.4.43 (antibiotics before skin incision), 1.6.29 (catheter removal). www.nice.org.uk/guidance/ng192/chapter/Recommendations
  • Operative Obstetrics 4e, Ch 22 Postpartum hemorrhage, p. 280 (oxytocin 5-10 IU slow IV bolus or 10-40 IU in 1000 ml at 150 ml/h).
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Table 1: cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision. academic.oup.com/ajhp/article/70/3/195/5112717
  • WHO. Robson Classification: Implementation Manual. 2017. Group 1 = nulliparous, single cephalic, 37 weeks or more, spontaneous labour. www.who.int/publications/i/item/9789241513197

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.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

This page cannot be printed from the browser. Use the Download printable PDF button on the page.