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Discipline

: Obstetrics & Gynaecology

Sub Discipline

: Obstetrics And Gynaecology

Document Title

: Obstetrics Procedure Note

CERVICAL CERCLAGE

Gestation - Cervical Cerclage (weeks)

Indication - Cervical Cerclage

3 previous mid-trimester miscarriages

2 previous mid-trimester miscarriages

3 or more pregnancy losses

Cervical incompetence diagnosed by HSG or USS

Others, specify

Pre-Op Preparation

None

Tocolysis - Oral

Ultrasonography

Use of Foleys Catheter

Tocolysis - IV / IM

Others, specify

Vaginal Examination

Position Of Cervix

Comments

Uterus

Present

11 - 14 weeks size

Other Findings

Operative Procedure

Method Of Cerclage

Shirodkar Cerclage

Mcdonals Cerclage

Arabin Pessary

Size

Others, specify

Anaesthesia

None

General Anesthesia

Spinal Anesthesia

Epidural Anesthesia

Cervical Block

Others, specify

Suture For Cerclage

Prolene tape

Mersilene tape

Prolene suture

Silk

Others, specify

Needle

Atraumatic needle

Site Of Knot

Anterior

Posterior

Others, specify

Date And Time Operation Started

Date And Time Operation End

Post Operative Orders

Analgesia

Intra Operative Complications

Miscarriage

Rupture of membrane

Cervical tear

Infections

Bleeding

Failed Cerclage

Others, specify

Comments

TYPE OF PROCEDURE

CYTOLOGICAL SMEAR

Screening Summary

Cytological Smear

Specimen Type

Sampling Site

Screening Type

Screening Location

Previous Result

Clinical Summary

Hormonal Status

LMP

Type Of Contraceptive Used

Treatment History

Symptoms

Cervix

Comments

EXTERNAL CEPHALIC VERSION (ECV) PROCEDURES

Indication

Method

Forward

Number Of Attempt

1

Tocolysis

YesNo

Ultrasound Guidance

No

Complications

Fetal Distress

Successful

YesNo

Comments

INSERTION OF VAGINAL PESSARY

Vaginal Findings

Urethra

Normal

Urethrocele

Stress incontinence

Injury

Urethral prolapse

Bullous lesions

Caruncle

Urinary leak

Others, specify

Vagina

Normal

Septum

Stenosis

Discharge present

Inflamed

Cystocoele

Rectocoele

Enterocoele

Vaginal cyst

Others, specify

Uterus

Absent

Insertion Of Vaginal Pessary

Indications - Vaginal Pessary

UV prolapse

Others, specify

Types Of Pessary

Ring pessaryHodge pessaryOthers, specify

Size Of Pessary (Mm)

Removal Of Pessary

Other Findings

Comments

REMOVAL OF IUD

Type Of IUD

MultiloadCopper - TProgesterone - releasing IUSOthers, specify

Duration Of IUD Used

IUD Thread Present In Vagina

YesNo

Comments

Complications IUD Removal

None

Abortion

Others, specify

Comments Removal Of IUD

TERMINATION OF PREGNANCY (TOP)

Termination Of Pregnancy

Gestation - TOP (week)

Indications - Top

Threat to maternal physical health

Threat to maternal mental health

Comments

Vaginal Examination

Vulva

NormalAbnormal

Atrophic

Vagina

Atrophic

Comments

Position Of Cervix

Comments

Length Of Cervix (Cm)

Dilatation Of Cervical Os (Cm)

Uterus

Present

11 - 14 weeks size

Method Of Top

Method Of Top

Medical

Comments

Anaesthesia - Top

Anaesthesia - Top

None

General Anaesthesia

Spinal Anaesthesia

Epidural Anaesthesia

Cervical Block

Sedation

Others, specify

Comments

Complications -Top

Complications -Top

None

Incomplete evacuation

Retained POC

Perforation of uterus

Haemorrhage

Infections

Endometritis

Cardiac Arrest

Pulmonary Embolism

Uterine rupture

Maternal depression

Psychotic disorders

Liver Impairment

Diarrhoea

Asthmatic attacks

Respiratory arrest

Amniotic fluid embolism

Thromboembolism

Others, specify

Comments

Other Findings

Comments On Top

INSTRUMENTAL DELIVERY

Date And Time Started

Date And Time Ended

Duration

hour(s)

Indication

Fetal Distress

Maternal distress

Prolonged 2nd Stage

Inadequate maternal effort

Prophylactic

Maternal Heart Disease

Maternal Hypertension

Malposition

After coming head for Breech

Cord Prolapse

For second twin

Prematurity

Rotational

Others, specify

Consent

YesNo

Consultation With Specialist

YesNo

Date And Time

Specialist

Pre Requisites

Fully Dilated Os

YesNo

Position of Fetal Head

Ruptured Membrane

YesNo

Cpd Excluded

YesNo

Catheterization

YesNo

Head Palpable Per Abdomen

YesNo

Station Of The Fetal Head

Caput

cm

Moulding

Fetal Heart Rate

Estimated Birth Weight

grams

FORCEPS DELIVERY

Forceps Delivery

Type Of Forceps

Wrigley's forceps

Neville Barnes'

Others, specify

Procedure

Patient In Lithotomy Position

No

Aseptic Technique Applied

No

Analgesia

Vaginal Examination Done

YesNo

Failure To Apply

YesNo

Failure To Lock

YesNo

Failure To Descend

YesNo

Number Of Attempt

1>3

Descent Of The Head With Traction

YesNo

Episiotomy Performed

YesNo

Difficulty In The Delivery Of The Shoulder And Trunk

YesNo

Obstetric Trauma/Tear

YesNo

Forcep Delivery

SuccessfulFailed

Remarks

VACUUM DELIVERY

Vacuum Delivery

Type Of Vacuum

Cup Size

Procedure

Patient In Lithotomy Position

YesNo

Aseptic Technique Applied

YesNo

Analgesia

Vaginal Examination Done

YesNo

Episiotomy

YesNo

Pressure

Pressure (Kpa/Mm/Hg)

kPammHg

Cup Slipped

YesNo

No Of Application

No Of Traction

Vacuum Delivery

SuccessfulFailed

VAGINAL BREECH DELIVERY

Consent

YesNo

Consultation With Specialist

YesNo

Date And Time

Specialist

Fetal Heart Rate

Estimated Birth Weight

grams

Type Of Breech

Method of Delivery

Assisted

Comments

Delivery Of After Coming Head

Neville Barnes forceps

Wrigley's forceps

MSV manoeuvre

Burns-Marshall method

Others, specify

Comments

Analgesia

None

General Anaesthesia

Epidural

Spinal

Perineal infiltration with LA

Pudendal block

Entonox

Sedation

Others, specify

Comments

Outcome

SuccessfulUnsuccessful

Complication

None

Head entrapment

Intracranial haemorrhage

Dislocation of neck

Erb-Duchenne paralysis

Damage to sternomastoid muscles

Genital oedema & ecchymosis

Dislocation of shoulder

Fracture of clavicle

Fracture of humerus

Prolapsed Cord

Fracture of femur

Disruption of knee joint

PPH

Vaginal Tear

Site

Haematoma

Site

Perineal tear

Bladder injury

Others, specify

INSTRUMENTAL DELIVERY COMPLICATIONS

Instrumental Delivery Complications

Maternal

Perineal Tear

Vaginal Tear

YesNo

Size

Haematoma

No

Estimated Blood Loss (Mls)

Bladder Or Urethral Injury

No

Uterine Or Cervical Injury

No

Comments

Fetal

Asphyxia

No

Cord Blood Ph

Please Update Method

Cephalohaematoma

No

Facial Nerve Palsy

No

Trauma Of The Soft Tissue Over The Face And Forehead

No

Others, Specify

Comments

CAESAREAN

Date Time Started

Date Time Finished

Indication For Surgery

Anaethesia (Type)

Epidural

Type of Caesarean Section

Elective

Skin Incision

Midline Longitudinal

Findings

Peritonial Cavity

Lower Segment

Engagement of Presenting Part

No

Placental Site

Placental Abnormality

Uterus

Tubes

Ovaries

Liquor

Abnormalities of Other Structures

Post Operative Urine

No

Blood Stained

No

Blood Loss

ml

Skin Closure

Difficulties Encountered During Operation

Baby

No of babies delivered

Apgar Score

1 Min

5 Mins

Abnormalities

OPERATIVE PROCEDURE

Date Time

Type Of Anaesthesia

Gross Specimen

Cytology

Pre-operative Diagnosis

Post-operative Diagnosis

Type of Operation

Operative Findings

MANAGEMENT

Plan

Follow Up

Performed By

SIGNATURES

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