Creates structured C-section operative reports with indication, technique, and estimated blood loss. Use when documenting cesarean deliveries, recording operative findings, or writing C-section reports.
Creates structured C-section operative reports with indication, technique, and estimated blood loss. Use when documenting cesarean deliveries, recording operative findings, or writing C-section reports.
Creates structured C-section operative reports with indication classification, surgical technique details, and estimated blood loss per ACOG documentation standards.
Why This Skill Exists
Cesarean delivery accounts for approximately 32% of all deliveries in the United States. Each operative report becomes a permanent medicolegal document and is the primary reference for future delivery planning (TOLAC candidacy), surgical complications, and malpractice defense. ACOG Practice Bulletin No. 205 emphasizes that the type of uterine incision must be clearly documented because it determines whether trial of labor after cesarean (TOLAC) is appropriate in subsequent pregnancies. Incomplete operative reports — particularly missing incision type, adhesion findings, or blood loss — represent a significant liability and quality gap.
This skill produces a complete, defensible C-section operative report that captures every required element from skin incision to skin closure.
Checkpoint A: Pre-Draft Intake (Mandatory)
Indication for cesarean — elective repeat, labor arrest, non-reassuring fetal status, malpresentation, placenta previa, other? (Default: extract from provider note)
Urgency classification — scheduled, urgent, or emergent? Decision-to-incision time if emergent? (Default: determine from context)
Prior surgical history — number of prior cesareans, type of prior uterine incision, known adhesions? (Default: review prior operative reports)
Anesthesia type — spinal, epidural, combined spinal-epidural, general? (Default: from anesthesia record)
Gestational age at delivery — weeks + days? (Default: from prenatal record)
Antibiotic prophylaxis — drug, dose, timing relative to incision? (Default: cefazolin 2 g IV within 60 minutes, 3 g if BMI ≥ 40)
Patient positioning and preparation — supine with left lateral tilt, Foley catheter placed? (Default: standard)
Surgical team — surgeon, first assist, scrub tech, circulator, anesthesiologist, pediatric team present? (Default: collect from OR log)
Documents to Request
Preoperative consent form (signed, with indication documented)
Anesthesia record
Prior cesarean operative reports
Intraoperative nursing record
Neonatal resuscitation record (if applicable)
Pathology request (if specimens sent)
Step 1: Document Preoperative Elements
The operative report must begin with:
Patient identification — name, MRN, date of birth
Date and time of surgery — incision time and closure time
Preoperative diagnosis — e.g., "Term pregnancy with arrest of active phase labor"
Postoperative diagnosis — may differ (e.g., "Term pregnancy with arrest of active phase labor; dense adhesions from prior cesarean")
Indication for cesarean — per ACOG categories:
Failed induction (document that ripening + oxytocin criteria were met)
Arrest of first stage (≥ 6 cm, ruptured membranes, 4 hrs adequate / 6 hrs inadequate contractions)
Arrest of second stage (minimum time thresholds met per parity/epidural status)
Non-reassuring fetal status (state NICHD Category)
Malpresentation (breech, transverse)
Placenta previa / vasa previa / accreta spectrum
Prior classical or T-incision (contraindication to TOLAC)
Anesthesia type and adequacy
Antibiotic prophylaxis — drug, dose, time administered relative to incision
Always state the uterine incision type in plain language — "Low transverse uterine incision was made and extended bluntly bilaterally." This sentence determines TOLAC eligibility for all future pregnancies.
Document extensions immediately — any J, T, or vertical extension must be captured in the operative report, as it changes future delivery counseling.
Use ACOG-consistent indications — never write "failure to progress" without specifying whether it was first-stage arrest, second-stage arrest, or failed induction with the supporting time and contraction criteria.
Distinguish elective from indicated — a scheduled repeat cesarean at 39 weeks is "elective repeat" not "failed TOLAC."
Record decision-to-incision time — for emergent cesareans, the benchmark is < 30 minutes; document the actual time and any delays with explanations.
Include a future delivery statement — e.g., "Patient is a candidate for TOLAC with one prior low transverse cesarean" or "Classical uterine incision — TOLAC is contraindicated."
