Normal Intraoperative Findings Documentation for Cesarean Section
For a routine, uncomplicated elective low transverse Pfannenstiel cesarean delivery at 39 weeks, document the following normal intraoperative findings:
Preoperative Preparation
- Antibiotic prophylaxis: First-generation cephalosporin (e.g., cefazolin 2g IV) administered within 60 minutes prior to skin incision 1, 2
- Skin preparation: Chlorhexidine-alcohol prep to abdomen 1, 2
- Anesthesia: Regional anesthesia (spinal or epidural) 1
- Patient positioning: Supine with left lateral tilt
- Normothermia maintained: Forced air warming device applied, IV fluids warmed 1
Surgical Findings
Abdominal Entry
- Skin incision: Low transverse Pfannenstiel incision made with scalpel or diathermy 3
- Subcutaneous tissue: Opened with diathermy, normal thickness and appearance 3
- Fascia: Sharp midline incision, extended bluntly bilaterally 3
- Rectus muscles: Separated bluntly in midline without cutting 3
- Peritoneum: Entered bluntly, extended bluntly 3
Intra-abdominal Survey
- Uterus: Gravid, appropriate size for gestational age, no fibroids noted
- Bladder: Normal appearance, not adherent to lower uterine segment (bladder flap creation omitted per current evidence) 3
- Adnexa: Bilateral ovaries and fallopian tubes normal in appearance
- Peritoneal cavity: No adhesions, no free fluid, no abnormalities noted
Uterine Entry and Delivery
- Hysterotomy: Low transverse uterine incision made sharply, extended bluntly in cephalo-caudad direction 1, 3
- Amniotic fluid: Clear, adequate volume
- Placenta location: Fundal/anterior/posterior (specify), not overlying incision site
- Fetal delivery: Manual delivery of vertex presentation, no difficulty encountered 3
- Cord clamping: Delayed cord clamping performed at 60-120 seconds 1
- Infant: Live-born male/female infant with good tone and cry, handed to pediatric team
Placental Delivery and Hemostasis
- Placenta: Delivered spontaneously with gentle cord traction, intact with three-vessel cord 3
- Membranes: Complete
- Uterine cavity: Explored, no retained products
- Uterotonic agents: Oxytocin infusion initiated; carbetocin or additional agents (misoprostol/methergine) as per protocol 3
- Estimated blood loss: 500-800 mL (normal range for cesarean delivery)
Closure
Uterine Closure
- Hysterotomy closure: Two-layer closure with delayed absorbable suture 1
- Hemostasis: Adequate, no active bleeding from uterine incision
Abdominal Closure
- Peritoneum: Left open (not closed per evidence-based recommendations) 1
- Fascia: Closed with continuous running absorbable suture, hemostasis adequate
- Subcutaneous tissue: Reapproximated with absorbable suture (if ≥2 cm thickness) 1
- Skin: Subcuticular closure with absorbable suture 1
Final Assessment
- Sponge and instrument counts: Correct x2
- Hemostasis: Excellent throughout
- Patient tolerance: Procedure well-tolerated, vital signs stable throughout
- Specimens: Placenta sent to pathology (if indicated per institutional protocol)
Key Documentation Points
This documentation template reflects evidence-based surgical technique that prioritizes maternal safety and optimal outcomes 1, 2, 3. The specific technical details (blunt expansion of hysterotomy, omission of bladder flap, peritoneum left open, two-layer uterine closure, subcuticular skin closure) are based on strong guideline recommendations that reduce blood loss, operative time, and postoperative complications 1.
Common pitfall to avoid: Do not document "bladder flap created" as current evidence recommends omitting this step 3. Similarly, avoid documenting peritoneal closure as it increases operative time without improving outcomes 1.