What are the soap notes for a pregnant patient undergoing a cesarean section (CS)?

SOAP Note Documentation for Cesarean Section

For a pregnant patient undergoing cesarean section, document using the standard SOAP format with specific focus on obstetric indication, risk stratification, perioperative protocols, and enhanced recovery elements as outlined by ACOG and ERAS guidelines. 1, 2

Subjective (S)

Document the following specific elements:

• Primary indication for cesarean delivery: Record the exact obstetric indication (repeat cesarean, breech presentation, failed induction, fetal distress, maternal request, or other specific indication) 1
• Obstetric history: Number of prior cesarean sections, inter-delivery interval, type of prior uterine incision (low transverse vs classical), and any complications from previous deliveries 1
• Current pregnancy course: Gestational age, prenatal care attendance, and pregnancy complications including gestational diabetes, hypertension, or preeclampsia 1
• Labor status: Whether patient is in active labor, membrane status (intact vs ruptured), and duration of rupture if applicable 1, 2
• Symptoms: Document dyspnea, chest pain, palpitations, or other cardiovascular symptoms if relevant 3
• Fasting status: Time of last solid food and clear liquid intake 2

Objective (O)

Record these specific clinical parameters:

• Vital signs: Blood pressure, heart rate, temperature, oxygen saturation 3
• Physical examination findings: Abdominal examination, fetal heart rate pattern, cervical examination if applicable 1
• Laboratory values: Complete blood count (hemoglobin for anemia assessment), blood type and screen, glucose if diabetic 2
• Gestational age confirmation: Based on best available clinical information, ideally 38 weeks for scheduled cesarean 3
• Comorbidity assessment: Document presence of hypertension, diabetes, cardiac disease (particularly hypertrophic cardiomyopathy if relevant), or other significant conditions 3, 2
• Group B Streptococcus status: If screening performed at 35-37 weeks 2

Assessment (A)

Synthesize the clinical picture:

• Primary diagnosis: Term pregnancy at [gestational age] weeks, [specific indication] for cesarean delivery 1
• Risk stratification: Classify as clean (class I) if scheduled before membrane rupture without chorioamnionitis, or clean-contaminated (class II) if in labor or with ruptured membranes 3
• Comorbidity impact: Assess how maternal conditions affect surgical and anesthetic planning 3
• Anesthetic risk assessment: ASA classification (typically ASA II-III for obstetric patients) 4

Plan (P)

Preoperative Management

Antibiotic prophylaxis (critical timing element):

• Administer weight-based cefazolin IV within 60 minutes before skin incision 3, 1, 2
• Add azithromycin 500mg IV for patients in labor or with ruptured membranes to reduce infectious morbidity 3, 1, 2
• This represents enhanced coverage for clean-contaminated cases 3

Skin preparation:

• Use chlorhexidine-alcohol for abdominal preparation (preferred over aqueous povidone-iodine) 3, 2
• Perform vaginal preparation with povidone-iodine solution 3, 2

Anesthetic plan:

• Regional anesthesia (spinal or epidural) is the preferred method as part of enhanced recovery protocol 3, 5
• For patients with hypertrophic cardiomyopathy, use general or epidural anesthesia with precautions to avoid hypotension 3
• Administer intrathecal morphine 50-100μg for superior postoperative analgesia 1, 5

Hypothermia prevention:

• Apply forced-air warming device 3, 5, 2
• Warm intravenous fluids 3, 5, 2
• Maintain operating room temperature at 21-25°C 2

Fluid management:

• Maintain perioperative euvolemia; avoid fluid overload 3, 5, 2

Intraoperative Management

Surgical technique:

• Perform blunt expansion of transverse uterine hysterotomy to reduce blood loss 3
• Close hysterotomy in two layers to reduce future uterine rupture risk 3, 1
• Do not close peritoneum (increases operative time without benefit) 3
• Reapproximate subcutaneous tissue if ≥2 cm depth 3
• Use subcuticular suture for skin closure 3

Neonatal care:

• Delay cord clamping for at least 1 minute for term births 5
• Ensure neonatal resuscitation capacity available 2
• Maintain newborn temperature 36.5-37.5°C 5

Multimodal analgesia:

• Administer paracetamol and NSAIDs intraoperatively after delivery 1, 5

Postoperative Management

Enhanced recovery protocols:

• Remove urinary catheter immediately after surgery 1
• Allow regular diet within 2 hours after cesarean 1, 5
• Encourage early mobilization 5
• Administer scheduled multimodal analgesia to minimize opioid use 1, 5

Uterotonic management:

• Administer slow IV oxytocin infusion (<2 U/min) after placental delivery to prevent hemorrhage 3
• Avoid methylergonovine due to risk of vasoconstriction and hypertension 3

Thromboprophylaxis:

• Apply elastic support stockings and encourage early ambulation 3
• Consider pharmacologic thromboprophylaxis for patients with additional VTE risk factors 5

Monitoring:

• Continue hemodynamic monitoring for at least 24 hours postoperatively, as delivery causes significant fluid shifts that may precipitate heart failure in patients with structural heart disease 3
• Monitor pulse oximetry and continuous ECG as required 3

Discharge planning:

• Provide standardized written discharge instructions including wound care, pain management expectations, warning signs, and individualized opioid prescribing 1

Critical Pitfalls to Avoid

• Never delay antibiotic administration beyond 60 minutes before incision 1, 2
• Never omit azithromycin in patients in labor or with ruptured membranes 1
• Never use single-layer uterine closure (increases future uterine rupture risk) 1
• Never use misoprostol for cervical ripening in patients with prior cesarean (increases uterine rupture risk) 1
• Avoid methylergonovine for postpartum hemorrhage management 3

Special Populations

Patients with hypertrophic cardiomyopathy:

• Vaginal delivery is preferred; reserve cesarean for obstetric or emergency cardiac indications 3
• If cesarean required, use regional anesthesia with careful blood pressure management to avoid hypotension 3
• Continue beta blockers perioperatively (metoprolol, bisoprolol, labetalol preferred; avoid atenolol) 3

HIV-positive patients:

• Scheduled cesarean at 38 weeks reduces transmission if HIV RNA >1,000 copies/mL 3
• Administer continuous IV zidovudine beginning 3 hours before surgery 3