Repeat caesarean section (previous LSCS)

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
• dense adhesions making entry and delivery slower
• bladder injury (higher than at a first caesarean)
• bowel or ureteric injury
• placenta accreta and hysterectomy if bleeding cannot be controlled
• wound infection
• thromboembolism
• scar rupture and placenta accreta in future pregnancies
• fetal laceration

Pre-operative details for this operation

1. Details of previous caesarean(s)number, year, indication, type of uterine incision (from old notes if available), complications, interval since last
2. Reason for repeat caesarean (not trial of labour)Maternal request after counsellingTwo or more previous caesareansPrevious classical / T incisionPrevious rupture or dehiscenceObstetric indication (state)Failed trial of labour
3. Placental site on ultrasoundplacenta praevia and accreta over the scar excluded or not
4. Gestational agefor elective: 39 weeks or more, or reason for earlier
5. Urgency category1234
6. Blood grouped and cross-matchedgroup, Rh, units reserved
7. Consent for tubal ligation (if requested)Taken, separate formNot requested
8. Bladder catheterisedYes

Anaesthesia and position

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

Operative findings

1. Old skin scartype (Pfannenstiel / vertical), keloid or healthy
2. AdhesionsNoneFilmyDensebetween what: rectus / omentum / bladder / uterus; how dealt with
3. BladderNormal positionPulled up over the lower segmentAdherent to the scar
4. Previous uterine scarHealthyThinned (window), membranes visibleDehiscence (length)Rupture
5. Lower uterine segmentWell formedPoorly formedThinned out
6. LiquorClearMeconium stainedBlood stained
7. Placentasite, relation to scar, delivered complete / incomplete, adherent areas
8. Uterus, tubes and ovariesnormal / fibroids / adhesions
9. 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; through old scar or not
3. Rectus sheath and peritoneum openedadhesions: where, divided sharp or blunt
4. Bladder separated from lower segmentBluntSharp dissection (adherent bladder)Not needed
5. Uterine incisionLow transverseLow verticalClassicalInverted T / J extensionthrough old scar or above it
6. Delivery of babyvertex / breech; forceps or fundal pressure if used
7. Cord clampingdelayed (time) or immediate (reason)
8. Uterotonicdrug, dose, route, time
9. Placenta and membranes deliveredControlled cord tractionManual removal
10. Uterine closurenumber of layers, suture material and size, angles secured separately
11. Bladder checked for injuryurine colour; dye / fluid test if doubtful
12. Haemostasisuterine suture line, bladder area, broad ligaments (no bulge)
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 more than 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 (e.g. adherent area)
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. Cathetertime of removal; 7 to 10 days if bladder was repaired
6. Urinecolour and output; report haematuria
7. Oral intakesips / liquids / soft diet from when
8. Thromboprophylaxisearly mobilisation, stockings, LMWH if risk factors
9. Breastfeedingstart within the first hour
10. InvestigationsHb on day 1
11. Discharge advicecopy of this note to the patient; scar findings explained for the next pregnancy

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