Dilation and Curettage Procedure Note (Early Pregnancy Loss)

Date/Time: [Procedure date and time] (Include start and end times if available.)

Location: [office / ED / L&D / OR]

Primary Operator: [Name and credentials]

Assistant(s): [Name(s) and credentials / None]

Pre-procedure Diagnosis: [Diagnosis and gestational age]

Post-procedure Diagnosis: [Diagnosis] (Update if changed based on intraoperative findings.)

Procedure Performed: [suction dilation and curettage / manual vacuum aspiration / electric vacuum aspiration] (Specify exact technique; avoid generic "D&C" without method.)

Indication and Clinical Context

[Clinical indication, gestational age, presenting symptoms, and pertinent history] (Include indication such as hemorrhage, infection, retained products, patient preference, or medical comorbidities; gestational age by LMP and/or ultrasound; presenting symptoms; and relevant history including prior uterine/cervical surgery, bleeding disorders, or allergies. Summarize in 2–4 sentences.)

Diagnostic Basis

[Ultrasound findings and diagnostic certainty statement] (Include when ultrasound informed EPL diagnosis or ectopic was in differential. Document ultrasound date and key findings: gestational sac location, CRL with or without cardiac activity, MSD with or without embryo; how intrauterine location was established; and diagnostic certainty statement. Omit section if EPL was clinically obvious without imaging contribution.)

Informed Consent

[Consent discussion and documentation] (Document that alternatives—expectant, medical, surgical—were discussed; material risks reviewed including bleeding, infection, perforation, retained tissue, intrauterine adhesions, and anesthesia risks; patient questions answered; and written consent obtained. Note interpreter use if applicable. For emergent verbal consent, state explicitly with reason.)

Time-Out

[Time-out verification] (Document that time-out was performed verifying correct patient and procedure. If not performed due to emergency, document reason and alternative verification used.)

Pre-Procedure Preparation

• Antibiotic prophylaxis: [Drug, dose, route, and timing / Not given—reason]
• Rh status/RhIg: [Rh status]; [RhIg administered with dose and timing / Deferred—reason] (Document rationale per institutional protocol.)
• Cervical preparation: [Agent, dose, route, and timing / None required]
• Anesthesia/analgesia: [paracervical block / local only / moderate sedation / MAC / general anesthesia] (For paracervical block, specify agent and volume. If anesthesia team involved, reference anesthesia record.)
• Positioning and prep: [Position confirmed; antiseptic prep solution]

Procedure Details

• Exam: [Uterine size and position; cervical status; adnexal findings]
• Cervical access: [Speculum type; tenaculum placement site; paracervical block details if administered]
• Sounding: [Uterine depth in cm; direction] (If not performed, state reason.)
• Dilation: [Dilator type; final dilation size in mm / Cervix already dilated to size]
• Evacuation: [manual suction / electric suction]; [Cannula size in mm and type]; [Vacuum setting if applicable]; [Tissue obtained] (Note ultrasound guidance if used.)
• Sharp curettage: [Instrument, extent, and indication / No sharp curettage performed]
• Hemostasis: [Cervical bleeding management; uterotonics if given with drug, dose, and route; final bleeding status]
• Completion: [Basis for determining completion] (Avoid stating "complete" unless objectively verified by ultrasound.)

Findings, Blood Loss, and Complications

Findings: [Uterine characteristics; tissue description; abnormalities if any]

Estimated Blood Loss: [Volume in mL] (If minimal, anchor estimate, e.g., "minimal, <25 mL".)

Complications: [None / Complications with management] (Never leave blank or infer absence.)

Specimens

[Specimen type]; [Disposition: sent to pathology / held per policy / genetic testing ordered]; [Gross inspection findings: villi identified or not identified]; [Patient wishes regarding tissue if documented] (Do not leave blank. If no specimen obtained, state reason.)

Post-Procedure Status

[Patient tolerance; vital signs; recovery location; symptom management; disposition; medications given or prescribed including analgesics, antibiotics, RhIg, or contraception as applicable]

Counseling and Follow-Up

• Expected course: [Bleeding and cramping expectations; possible passage of small clots]
• Warning signs reviewed: [heavy bleeding (≥2 pads/hour for 2 hours) / fever ≥38°C / worsening pelvic pain / foul-smelling discharge / persistent dizziness]
• Activity: [Pelvic rest guidance]
• Follow-up: [Timing and modality]
• Contraception: [Plan documented / Declined / Deferred]
• Emotional support: [Grief resources offered]