SOAP Note Documentation for Cesarean Section
Subjective (S)
Document the indication for cesarean delivery clearly, as this drives all subsequent clinical decisions and medicolegal documentation. 1
- Chief complaint/Indication: Record the specific obstetric indication (e.g., repeat cesarean section, breech presentation, failed induction, fetal distress, maternal request) 1
- Obstetric history: Number of prior cesarean sections (critical for risk stratification), inter-delivery interval if applicable, type of prior uterine incision (low transverse vs. classic), and any complications from previous deliveries 2
- Current pregnancy course: Gestational age, prenatal care attendance, any complications (gestational diabetes, hypertension, preeclampsia) 1
- Labor status: Whether patient is in labor, membrane status (intact vs. ruptured), and duration if applicable 3, 1
- Allergies and medications: Document all allergies and current medications, particularly anticoagulants or antiplatelet agents 1
- Last oral intake: Time of last solid food and clear liquids (clear liquids permitted up to 2 hours before surgery, light meals up to 6 hours) 1
- Symptoms: Pain level, contractions if present, vaginal bleeding, fetal movement 3
Objective (O)
Record all preoperative assessments and preparations that directly impact surgical safety and postoperative recovery. 1
- Vital signs: Blood pressure, heart rate, temperature, respiratory rate, oxygen saturation 1
- Weight: Current weight for weight-based antibiotic dosing (cefazolin dosing) 3, 1
- Physical examination:
- Laboratory values:
- Fetal heart rate monitoring: Baseline rate, variability, presence of decelerations 3
- Ultrasound findings if available: Placental location, estimated fetal weight, amniotic fluid volume, any scar defects from prior cesarean 2
Assessment (A)
State the primary obstetric diagnosis and all relevant risk factors that modify surgical approach and postoperative management. 2, 1
- Primary diagnosis: Term pregnancy at [gestational age] weeks, [indication for cesarean section] 1
- Risk stratification for complications:
- Uterine rupture risk: Document number of prior cesarean sections, inter-delivery interval (<18 months increases risk significantly), type of prior incision (classic scar is absolute contraindication to labor) 2
- Placental abnormalities: Risk increases with number of prior cesarean sections (placenta previa: 9/1,000 after one CS, 17/1,000 after two CS, 30/1,000 after three or more CS; placenta accreta: 12.9/10,000 after one CS to 78.3/10,000 after three CS) 2
- Infection risk: Higher if in labor or with ruptured membranes (requires enhanced antibiotic coverage) 3, 1
- Hemorrhage risk: Based on prior history, placental location, multiple gestation 4
- Anesthetic risk assessment: ASA classification, airway concerns, contraindications to regional anesthesia 1
- Neonatal risk factors: Prematurity, growth restriction, known anomalies requiring immediate neonatal resuscitation capacity 3, 1
Plan (P)
Preoperative Management
Administer prophylactic antibiotics within 60 minutes before skin incision using weight-based cefazolin, with azithromycin 500mg IV added for patients in labor or with ruptured membranes. 3, 1
- Antibiotic prophylaxis:
- Skin preparation: Chlorhexidine-alcohol preferred over povidone-iodine for abdominal prep 3, 1
- Vaginal preparation: Povidone-iodine vaginal prep if in labor or ruptured membranes to reduce endometritis (reduces risk from 8.3% to 4.3%) 3
- Anesthesia: Regional anesthesia (spinal or epidural) preferred over general anesthesia 1
- Hypothermia prevention: Maintain operating room temperature 21-25°C, forced air warming, warmed IV fluids 1
- IV access: Large-bore IV access (at least two sites if high hemorrhage risk) 4
- Blood products: Type and screen; cross-match if high-risk features present 4
Intraoperative Management
Use intrathecal morphine 50-100μg for superior postoperative analgesia, combined with multimodal non-opioid analgesics administered after delivery. 3
- Analgesia strategy:
- Neuraxial opioid: Intrathecal morphine 50-100μg (or diamorphine 300μg, or epidural morphine 2-3mg) 3
- After delivery: IV paracetamol (if not given preoperatively), IV NSAID (unless contraindicated), IV dexamethasone 4-8mg (provides analgesia and antiemetic effect) 3
- If no intrathecal morphine used: Consider TAP block, quadratus lumborum block, or local anesthetic wound infiltration 3
- Surgical technique to reduce future rupture risk:
- Joel-Cohen incision (low transverse) 3
- Blunt expansion of uterine hysterotomy 2
- Two-layer hysterotomy closure (reduces future uterine rupture risk) 2
- Non-closure of peritoneum 3
- Subcutaneous tissue reapproximation if ≥2cm thickness 2
- Subcuticular suture for skin closure (reduces wound complications vs. staples) 2
- Neonatal care:
Postoperative Management
Implement early recovery protocols including urinary catheter removal immediately after surgery, regular diet within 2 hours, and scheduled multimodal analgesia to minimize opioid use. 3
- Analgesia:
- Early recovery interventions:
- PONV prophylaxis: Multimodal approach with dexamethasone (already given intraoperatively), ondansetron as needed 3
- VTE prophylaxis: Pneumatic compression stockings (heparin not routinely recommended for uncomplicated cesarean) 3
- Glucose monitoring: Tight capillary blood glucose control, especially in diabetics 3, 1
- Abdominal binder: Apply postoperatively (reduces pain and improves mobilization) 3
Discharge Planning
Provide standardized written discharge instructions including wound care, pain management expectations, warning signs, and individualized opioid prescribing to minimize unnecessary consumption. 3
- Discharge counseling: Standardized written instructions 3
- Opioid prescribing: Individualized/stratified approach to reduce unnecessary consumption 3
- Warning signs: Fever, increasing pain, wound complications, heavy bleeding, signs of infection 3
- Follow-up: Routine postpartum visit timing, earlier if complications 3
- Future pregnancy counseling (if multiple prior cesarean sections): Increased risks of placental abnormalities, uterine rupture, need for early ultrasound in future pregnancies 2
Critical Pitfalls to Avoid
- Never use misoprostol for cervical ripening in patients with prior cesarean section (13% rupture rate in third trimester) 2
- Never delay antibiotic administration beyond 60 minutes before incision 3, 1
- Never omit azithromycin in patients in labor or with ruptured membranes (significantly reduces infectious morbidity) 3, 1
- Never use single-layer uterine closure (increases future rupture risk; always use two-layer closure) 2
- Never discharge without addressing multimodal analgesia (prevents opioid overuse and improves recovery) 3