Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Anesthesia: [Type of anesthesia used, e.g., spinal, epidural, general]
Anesthesiologist: [Anesthesiologist Name]
Assistant Surgeon (if applicable): [Assistant Surgeon Name]
Reason for Cesarean Delivery:
Briefly document the primary indication for the C-section (e.g., arrest of descent, fetal distress, breech presentation, placenta previa).
SOAP
Subjective (S):
Briefly document if the patient endorsed any preoperative concerns or allergies.
Objective (O):
Preoperative Assessment:
Briefly summarize relevant preoperative findings, including:
Vital signs
Fetal heart rate tracing
Estimated blood loss (EBL)
Intraoperative Findings:
Skin to Skin Time:
Document the time interval between delivery of the baby and skin-to-skin contact (if applicable).
Uterine Atony:
Describe the presence or absence of uterine atony (poor contraction of the uterus after delivery).
Estimated Blood Loss:
Document the estimated blood loss during the surgery.
Blood Transfusion (if applicable):
Document the type and amount of blood transfused, if any.
Fetal Weight and Apgar Scores:
Record the baby’s weight and Apgar scores at 1 and 5 minutes.
Placenta and Umbilical Cord:
Describe the appearance of the placenta and umbilical cord (e.g., complete, abnormalities).
Postoperative Assessment:
Briefly summarize relevant postoperative findings, including:
Vital signs
Blood loss in the recovery room
Pain assessment
Assessment (A):
Blood Loss:
Assess the amount of blood loss as normal, moderate, or excessive based on institutional guidelines.
Surgical Site:
Describe the surgical site (e.g., Pfannenstiel or midline incision) and closure (e.g., staples or sutures).
Plan (P):
Pain Management:
Describe the pain management plan, including medications and route of administration.
Diet:
Outline the planned diet advancement (e.g., clear liquids to regular diet).
Ambulation:
Describe the ambulation plan (e.g., early ambulation with assistance).
Urinary Output:
Address the plan for monitoring urinary output.
Bowel Function:
Briefly mention the plan for promoting bowel function (e.g., stool softeners).
Discharge Criteria:
Outline the criteria for discharge from the hospital (e.g., pain control, tolerating diet, ambulating independently).
Follow-up:
Schedule a follow-up appointment for postpartum care.
Additional Notes:
Document any unexpected intraoperative findings or complications.
Briefly mention any communication with the neonatologist regarding the baby’s condition.
Address any breastfeeding concerns or plans.
Note any patient education provided regarding incision care, pain management, and postpartum recovery.