Name MV Boli, age 42 Hospital #

Date xx Elective Caesarean Plus Bilateral Tubal Ligation

Time yy Indication: 2 previous caesarean and satisfied parity

Surgeons: Dr X Anaesthetist: Dr Z
Dr Y Scrub Nurse: name

Spinal Anaesthesia
Preliminaries done, bladder emptied with indwelling Foley’s catheter, per-
operative antibiotics given (ceftriaxone 1g IV)

I Transverse suprapubic (or state Pfannenstiel, Cohen’s, midline subumbilical)

F Old transverse suprapubic scar, marked fibrosis, bladder high on lower

segment, otherwise well-formed lower segment, normal liquor, cephalic not
engaged, male term infant in good condition, healthy placenta, fundal
attachment, normal uterus, ovaries and tubes normal.

P Old scar excised, knife dissection of sheath, rectus separated from sheath,
high intraperitoneal entry, bladder carefully dissected from lower segment
and pushed downwards to expose lower segment. Transverse lower segment
incision, membranes spontaneously ruptured, easy cephalic delivery, baby to
midwife. Placenta CCT, cavity swabbed clean.
Uterus closed in 2 layers, CCG 2 (or Vicryl 2), Angles secured.
BTL done (Pomeroy) → specimen to histology
Vicryl 2 to sheath.
Vaginal toilet done

S Interrupted nylon 2.0 to skin (or subcut vicryl 2.0)

Swab instrument count stated correct

EBL 350mls
Post op
Supine for 8 hours
IVI 3L/24hrs
Pethidine 50-100mg 4-6hrs PRN, max 400mg (plus anti-emetic) as charted
Antibiotics as charted (as per protocol)

Legible signature/name
 Name MV Boli, age 22 Hospital #
Date xx Emergency Caesarean
Time yy Indication: Undiagnosed Primip breech at 38 weeks in labour

Surgeons: Dr X Anaesthetist: Dr Z
Dr Y Scrub Nurse: name

Spinal Anaesthesia
Preliminaries done, bladder emptied with indwelling Foley’s catheter, per-
operative antibiotics given (ceftriaxone 1g IV)

I e.g. Pfannenstiel (or Cohen’s) or midline subumbilical etc

F Well-formed lower segment, scanty clear liquor, frank breech not engaged,
female term infant in good condition, healthy placenta, posterior
attachment, normal uterus (cavity no abnormalities), ovaries and tubes N.

P Routine high entry, utero-vesical junction peritoneum excised, and bladder

pushed downwards to expose lower segment. Transverse lower segment
incision, breech delivery, MSV to deliver head, baby to midwife. Placenta
CCT, cavity swabbed clean.
Uterus closed in 2 layers, CCG 2 (or Vicryl 2), Angles secured.

Vicryl 2 to sheath.
Vaginal toilet done

S Subcuticular, vicryl 2.0 to skin

Swab instrument count stated correct
EBL 450mls

Post op
Supine for 8 hours
IVI 3L/24hrs
Pethidine 50-100mg 4-6hrs PRN, max 400mg (plus anti-emetic) as charted
Antibiotics as charted (as per protocol)

Legible signature/name
 Name MV Boli, age 29 Hospital #
Date xx Emergency Caesarean
Time yy Indication: Fetal distress, suspected abruptio in severe pre-
eclampsia at 32 weeks

Surgeons: Dr X Anaesthetist: Dr Z
Dr Y Scrub Nurse: name

General Anaesthesia
Preliminaries done, bladder emptied with indwelling Foley’s catheter, per-
operative antibiotics given (ceftriaxone 1g IV)

I e.g. Pfannenstiel (or Cohen’s) or midline subumbilical etc

F Ascitic fluid intraperitoneal; poorly formed lower segment, blood stained

liquor, cephalic not engaged, male premature infant in poor condition,
placenta fundal, partially detached, 600ml retroplacental clot, Couvelaire
uterus, ovaries and tubes N.

P Routine high entry, utero-vesical junction peritoneum excised, and bladder

pushed downwards to expose poorly formed lower segment. Transverse
lower segment incision, cephalic delivery, baby to midwife. Placenta CCT,
cavity swabbed clean.
Uterus closed in 2 layers, Vicryl 2, Angles secured. Compressed manually
to ensure oozing stopped.
Vicryl 2 to sheath.
Vaginal toilet done

S Subcuticular, vicryl 2.0 to skin

Swab instrument count stated correct

EBL 300mls (plus 600 retroplacental clot)
Post op
Transfuse at least 2units fresh whole blood
IV oxytocin 20mU/min to continue; reassess need hourly
IV fluids assess with urine output (do not overload with crystalloids – 2L/24hrs
or increase as indicated)
Pethidine 50-100mg 4-6hrs PRN, max 300mg (plus anti-emetic) as charted
Antibiotics as charted (as per protocol)

Legible signature/name
 Name MV Boli age 51 Hospital #
Date xx Total abdominal hysterectomy and bilateral salpingo-
Time yy oophorectomy

Indication: Fibroid uterus and menorrhagia

Surgeons: Dr X Anaesthetist: Dr. Z

Dr. Y Scrub Nurse: name

General Anaesthesia
Preliminaries done, bladder emptied with indwelling Foley’s catheter, per-
operative antibiotics given (ceftriaxone 1g IV)

I e.g. Pfannenstiel (or Cohen’s) or midline subumbilical

F Large uterus with multiple fibroids (20weeks size). Normal ovaries and
tubes.

P Routine high entry, three pedicle hysterectomy done. Infundibular and

Uterine pedicles double ligated with Vicryl 2 after ureters identified
separately and out of the way. Bladder well pushed down. Vaginal angles
secured. Interrupted closure of vault (Vicryl 2). Uterosacrals transfixed
over vault.
Vicryl 2 to sheath.
Vaginal toilet done

S Subcuticular, vicryl 2.0 to skin

EBL 450mls
Post op
IV 3L/24 hrs
Pethidine 50-100mg 4-6hrs PRN, max 400mg (plus anti-emetic) as charted
Antibiotics as charted (as per protocol)

(post op HB to be done…. …State when)

Legible signature/name
 Name MV Boli, age 22 Hospital #
Date xx Vacuum delivery
Time yy Indication: LOT, delay in second stage

Dr X , Dr Y, Midwife Z

G2P1, singleton, 39 weeks, spontaneous labour, satisfactory progress in first

stage, delay in second stage (now 2 hours in second stage despite good
contractions 3 in 10).
Cephalic, 2/5 palpable, back on mothers left, FHH regular 140, no decelerations
with contractions. Seems moderate size fetus.

On V/E, mild caput, station +1, left occipito transverse (LOT), Ischial spine not
prominent, sacral curvature appears normal. Liquor normal (no meconium).

Placed in lithotomy, bladder emptied

Pudendal block, lignocaine 1%, 5ml, both sides
Metal vacuum cup, size 6cm easily applied on occiput 2-cm anterior to the
posterior fontanelle – (the flexion point - see overleaf)
Vacuum pressure gradually increased to 600kPa over 3 minutes (see overleaf)
Gradual traction with maternal effort during contraction and ceph noted to
rotate to OA and crowned. Vaginal delivery, Cord clamped and cut – baby in
good condition to midwife. (female, wt 3200g, AS 81 and 95)
Placenta CCT. IM oxytocin 10U given
No vaginal tears noted,.

Vagina checked – empty – no clots, no swabs

EBL 200mls

Legible signature/name
Vacuum delivery (continued)

Consent needs to be documented in notes

Pressures
A vacuum pressure of 0.6 to 0.8 kg/cm2 (500–600 mm Hg) (600 to 800
kPa) and an artificial caput succedaneum can be achieved in a linear, rapid
fashion in less than 2 minutes

Flexion point