GynaePulse
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Operation note template

For caesarean section and other surgery.

Source: RCS Good Surgical Practice

Include

  1. Date, time, surgeon, assistant, anaesthetist, type of anaesthesia.
  2. Operation and indication; category of urgency for CS.
  3. Incision; findings (liquor, presentation, placenta, uterus, adnexa).
  4. Procedure: delivery time, baby sex, Apgar, cord gases; placenta; uterine closure (layers); other steps.
  5. Estimated blood loss; any complication.
  6. Swab, needle and instrument counts correct; specimens.
  7. Closure: sheath and skin, sutures used.
  8. Post-op plan: observations, fluids, analgesia, antibiotics, VTE prophylaxis, catheter removal, when to eat.
  9. Advice for next pregnancy (e.g. VBAC suitable or not).
  10. Signature and printed name.
A summary for trained clinicians. Always check the full guideline, the patient in front of you and your hospital's protocol. Spotted an error? Tell us.