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Checklist for Cesarean section

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This checklist is part of the Gynsurgery guidelines used in an educational setting for residents in Ob-Gyn.

Preoperative Checklist

(Please indicate - Done, X - Not done, NA – Not applicable)

  1. ____ Give informed consent for possible complications of fetal injury, hemorrhage, endometritis, bowel injury, bladder injury, ureter injury, illeus, wound infection and risks in subsequent pregnancy such as uterine rupture, excessive adhesions and misplacentation (prevent incorrect expectations)
  2. ____ Inform patient of wound complications and their likelihood of occurrence (wound infection, hematoma, dehiscence, pain, cosmetic changes) along with complications of the primary procedures being performed (prevent incorrect expectations)
  3. ____ Clip abdominal/mons hair prior to surgery but no shaving (prevent infection)
  4. ____ Cleanse incision site prior to surgical prep with antibacterial soap (prevent infection)
  5. ____ Give prophylactic antibiotics up to 60 minutes prior to Cesarean section if possible (prevent endometritis)
  6. ____ Use preoperative vaginal betadine prep or intravaginal metronidazole gel (prevent endometritis)
  7. ____ Be familiar with uterine tourniquet techniques (prevent hemorrhage)

Intraoperative Checklist

Abdominal wall incision

  1. ____ Identify midline and anterior iliac spine and mark on skin the line of the incision if needed (prevent asymmetry of incision)
  2. ____ Start transverse incision at least 3-5 cm above symphysis pubis (prevent nerve transection)
  3. ____ Follow lines of Langer, curving transverse skin incision upward laterally so as not to transect cutaneous nerves (prevent nerve transection)
  4. ____ If removing old scar, excise subcutaneous tissue symmetrically (prevent poor cosmetic scar result)
  5. ____ Cut rectus fascia only to edge of rectus muscle, avoid lateral extension of incision into internal oblique muscle (prevent nerve transection)
  6. ____ Cauterize or ligate superficial epigastric vessels on transverse incision even if not bleeding at time of transection (prevent post operative bleeding)
  7. ____ Cauterize or ligate rectus perforating vessels on Pfannenstiel incision even if not bleeding at time of transection (prevent post operative bleeding)
  8. ____ Enter abdominal peritoneum as cephalad to the fascial incision as possible (prevent bladder injury)

Intraperitoneal

  1. ____ At initial entry into the peritoneal cavity, assess for adhesions of the bowel or omentum to the uterus, tubes, ovaries or peritoneum (prevent bowel injury)
  2. ____ Avoid packing bowel with dry sponges/lap packs (prevent postoperative illeus)
  3. ____ Ensure adequate room in rectus fascia incision and rectus muscle separation (prevent excessive time to delivery)
  4. ____ If head has descended deep into the pelvis, create bladder flap by dissecting peritoneum off of the lower uterine segment (prevent bladder injury)
  5. ____ If head has descended deep into the pelvis, anticipate need for an extra assistant to vaginally elevate the infant’s head in arrested descent labor cases (prevent excessive time to delivery)
  6. ____ Ensure good exposure of hysterotomy site, and consider blunt probing with scalpel handle or hemostat to enter uterus after partial incision (prevent fetal laceration)
  7. ____ Hold scapel with fingertip grip, not like a pencil, when making uterine incision (prevent fetal laceration)
  8. ____ Take adequate time when incising uterus, do not incise uterus in haste (prevent fetal laceration)
  9. ____ If performing a low transverse segment incision, complete uterine incision by tearing laterally instead of cutting, if possible, for LTCS (prevent uterine vessel hemorrhage/injury)
  10. ____ If performing a low transverse segment incision, when tearing hysterotomy, curve your tear in an upward direction laterally (prevent uterine vessel injury/hemorrhage) (prevent subsequent uterine rupture)

Delivery

  1. ____ Confirm position, presentation before rupture of membranes (prevent excessive time to delivery)
  2. ____ Elevate a well-descended head without flexing the wrist, (do not use the lower uterine segment as a fulcrum for your delivery hand ) (prevent bladder injury, prevent hemorrhage)
  3. ____ If breech:
    1. ____ have Piper forceps available
    2. ____ allow baby to deliver to the level of umbilicus (prevent fetal hip dislocation)
    3. ____ hold infant at pelvis, not legs or abdominal soft tissues (prevent hip dislocation)
    4. ____ avoid excessive rotary motion when delivering arms (prevent fetal hip dislocation)
    5. ____ avoid hyperextension of the head when delivering (prevent fetal neck injury)
    6. ____ avoid excessive force on legs and arms (prevent fetal extremity fracture)
  4. ____ Avoid excessive fundal pressure to prevent stimulating contractions (prevent excessive time to delivery)
  5. ____ Start pitocin after delivery of infant, before delivery of placenta (prevent hemorrhage)
  6. ____ Use routine uterotonic (methergine 0.2mg IM or misoprostol 800μg – 1mg ) in patients at high risk for atony (prolonged labor, hyperdistension of the uterus from polyhydramnios, twins), fibroids, uterine anomalies and recent tocolytics) (prevent uterine hemorrhage)
  7. ____ Express placenta rather than manually removing it (prevent endometritis)
  8. ____ Avoid use of sponges to wipe the endometrium (prevent endometritis)
  9. ____ In primary Cesarean sections, if manually dilating cervix with an instrument, avoid contaminating rest of surgical field (prevent endometritis)

Closing uterus and peritoneum

  1. ____ Identify the uterine vessels laterally before beginning to suture the hysterotomy incision (prevent hemorrhage)
  2. ____ Use an absorbable suture on uterine incision (not delayed absorbable) (prevent subsequent uterine rupture)
  3. ____ Use a two layer closure of the uterine incision (prevent subsequent uterine rupture)
  4. ____ When suturing near uterine vessels, palpate to make sure ureter not in area of intended suture (prevent ureter injury)
  5. ____ If manually dilating cervix with an instrument for postpartum blood egress, avoid contaminating rest of surgical field (prevent endometritis)
  6. ____ Close uterine incision with continuous locking suture (prevent hemorrhage)
  7. ____ Close abdominal peritoneum with suture (prevent future excessive adhesions)

Closing abdomenal wall

  1. ____ Observe subfascial space before closing fascia for bleeding (prevent hematoma)
  2. ____ Place fascial sutures approximately 1.0 cm from edge of fascia and approximately 1.0 cm apart (prevent wound dehiscence)
  3. ____ When closing anterior rectus fascia avoid subcutaneous tissue (prevent nerve entrapment)
  4. ____ Approximate fascia without tension on sutures (prevent wound dehiscence)
  5. ____ On transverse incisions, reapproximate Scarpa’s fascia superiorly to Scarpa’s fascia inferiorly and Camper’s to Camper’s if present (prevent poor cosmetic scar result)
  6. ____ Close subcutaneous tissue with running continuous absorbable suture if 2.0 cm of subcutaneous fat or more (prevent wound infection)
  7. ____ Place subcuticular stitches below the dermis (prevent poor cosmetic scar result)
  8. ____ Use a hypo allergenic skin adhesive rather than benzoin (prevent poor cosmetic scar result)
  9. ____ Close skin with steristrips or bonding (prevent poor cosmetic scar result)
  10. ____ Avoid skin staples or if used, remove by 3rd day (decrease postoperative incisional pain) (prevent poor cosmetic scar result)
  11. ____Use compression dressing for 48 hours before removing (prevent wound hematoma)

Signature: _________________________ Attending:_____________________ Date:______

Global Evaluation: |Initial learning| |Needs work| |Progressing| |Good for level| |OK on own|

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