Cesarean Delivery Operative Note

Date/Time of Procedure: [date and time]

Patient Name: [full name]

MRN: [medical record number]

DOB: [date of birth]

Gestational Age: [weeks + days]

Gravida/Para: [GxPx]

Singleton or Multiple: [singleton / twin / higher-order multiple]

Urgency: [scheduled / urgent / emergent]

Location: [OR / L&D OR / other]

Preoperative Diagnoses

• [Diagnosis/indication 1]
• [Diagnosis/indication 2]
• [Additional indications as stated]

(Include gestational age and all explicitly stated indications. Do not infer indications. If labor or membrane rupture occurred, add a brief summary: labor status, ROM status and duration, and relevant prior attempts such as ECV or TOLAC. Omit labor details if straightforward planned procedure without labor.)

Postoperative Diagnoses

• [Diagnosis/indication 1]
• [Diagnosis/indication 2]
• [New intraoperative finding(s) if any]

(Mirror preoperative diagnoses and add new intraoperative findings such as dense adhesions, incision extension, placenta accreta, or postpartum hemorrhage. Do not introduce unobserved conditions.)

Procedures Performed

1. [Primary / Repeat] cesarean delivery via [Pfannenstiel / vertical midline] skin incision and [low transverse / low vertical / classical / T extension / J extension] uterine incision
2. [Additional procedures as performed]

(Include bilateral salpingectomy or tubal ligation with technique, clinically meaningful adhesiolysis, cystoscopy, compression sutures, uterine artery ligation, or balloon tamponade. Include adhesiolysis only if prolonged, altered anatomy, or relevant for future surgical planning.)

Surgical Team

Primary Surgeon: [name, credentials]

Assistant(s): [name(s) and role(s)]

Anesthesia: [provider name(s)], [spinal / epidural / CSE / general] (Note conversion if occurred.)

Perioperative Measures

Antibiotic prophylaxis: [agent and dose] given [timing relative to incision] (If not given pre-incision, document rationale.)

VTE prophylaxis: SCDs placed

Surgical time-out: [performed / abbreviated due to emergent delivery—document rationale]

Operative Findings

• Fetal presentation/position: [cephalic / breech / transverse], [position if known]
• Amniotic fluid: [clear / meconium-stained / bloody / other]
• Placenta: [location], [appearance], [accreta spectrum if suspected or confirmed]
• Uterus: [appearance], [prior scar description if repeat cesarean]
• Adhesions: [location and severity] (Omit if minimal and not clinically significant.)
• Adnexa: [tubes/ovaries appearance] (Only include if visualized.)
• [Other pertinent findings]

(Document only clinically relevant findings. Do not document organs as normal unless inspected.)

Operative Description

(Concise narrative of standard technique; expand on deviations or complications.)

Entry

[Patient positioning]. [Skin incision type and location]. [Method of fascial and peritoneal entry]. [Bladder flap creation, especially if adhesions present].

Delivery

Uterine incision: [low transverse / low vertical / classical] with [method of extension]. Delivery: [standard / maneuvers for impacted head / breech extraction details]. Cord management: [delayed / immediate] clamping, [duration if delayed]. [Cord blood collection if performed].

Newborn

[Liveborn / stillbirth], [sex], birth weight [weight in grams]. Apgar scores: [1 min], [5 min]. (Continue at 5-minute intervals to 20 minutes if score remains below 7.) Disposition: [skin-to-skin with mother / to NICU / other]. [Neonatal resuscitation details if significant interventions required].

Placenta and Uterine Management

Placenta removed by [controlled cord traction / manual removal—include indication if manual]. Uterus [exteriorized / repaired in situ]. [Uterine cavity evaluation if performed]. Hysterotomy closure: [single-layer / double-layer]. [Repair of extensions or lacerations]. [Hemostatic interventions: additional sutures, compression sutures, uterotonics, balloon tamponade]. Hemostasis achieved.

Closure

Peritoneum [closed / not closed]. Fascia closed with [suture type and technique]. [Subcutaneous irrigation, hemostasis, or dead space closure if performed]. Skin closed with [staples / subcuticular suture]. [Dressing type].

Blood Loss and Counts

Quantified Blood Loss (QBL): [amount in mL] (If pending, document "QBL pending—addendum to follow" and ensure final note includes value.)

IV Fluids: [total mL]

Urine Output: [total mL], Foley in place

Blood Products: [type and units / None]

Uterotonics: [agents beyond routine oxytocin / None]

Counts: Correct x2 for sponges, sharps, and instruments (If discrepancy occurred, document what was missing, actions taken, and resolution.)

Specimens

• Placenta: [sent to pathology—indication / discarded per protocol]
• Cord blood gases: [obtained—arterial/venous / not obtained]
• Tubal segments: [sent to pathology] (If salpingectomy performed.)
• [Other specimens and destination]

Complications

[None / List each complication with timing, management performed, and status at case end]

Disposition

Maternal: [stable / guarded], to [PACU / L&D recovery / ICU]

Infant: [condition], to [with mother / NICU]

Postoperative Plan: [Key handoff items: antibiotic continuation, hemorrhage monitoring if QBL elevated, VTE prophylaxis, Foley removal timing if non-routine, pathology follow-up if indicated]

(Required elements—always document or use placeholder if pending: QBL, uterine incision type, counts result, complications statement, maternal and infant disposition.)