Date______________ Patient _______________________________ Date of birth___________ MR #____________ Physician _______________________________________ Gravidity/Parity__________________________________ Best estimated gestational age____________ Indication_________________ ❏ Patient has a complete medical history and physical examination ❏ Known allergies identified ❏ Medical factors that could affect anesthetic choices identified ❏ Patient counseled about risks and benefits of cesarean delivery versus trial of labor and vaginal delivery (1, 2) ❏ Consent form signed as required by institution ❏ Appropriate preoperative and pertinent prenatal laboratory test results (eg, group B streptococci or hematocrit) available (3) ❏ Antibiotic prophylaxis administered within 60 minutes before incision (4) ❏ Appropriate deep vein thrombosis prophylaxis administered (3, 5) ❏ Yes ❏ No: Reason:____________________________________ ❏ Presence of fetal heart tones documented before incision (6) ❏ Yes ❏ No: Reason:___________________________________ ❏ Risk factors identified: ❏ If at risk of bleeding more than 1,000 mL, adequate intravenous access and fluids planned and packed cells and blood products available ❏ Airway ❏ Allergies ❏ Notification of neonatal or pediatric departments if necessary ❏ A “time out” is conducted before the start of surgery to confirm the patient's name, allergies, and consent; to confirm the surgery to be performed; and to identify team member names and roles (7) ❏ Surgical counts performed before incision (surgical counts are reconfirmed postoperatively) References 1. Vaginal birth after cesarean delivery. Practice Bulletin No. 115. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:786–90. 2. Surgery and patient choice. ACOG Committee Opinion No. 395. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;111:243–7. 3. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Intrapartum and postpartum care. In: Guidelines for perinatal care. 6th ed. Elk Grove Village (IL): AAP; Washington, DC: ACOG; 2007. p. 139–74. 4. Antimicrobial prophylaxis for cesarean delivery: timing of administration. Committee Opinion No. 465. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:791–2. The American College of Obstetricians and Gynecologists Women’s Health Care Physicians ✓ Patient Safety Checklist PREOPERATIVE PLANNED CESAREAN DELIVERY Number 4 • December 2011 (continued) Reaffirmed 2014 References (continued) 5. Obesity in pregnancy. ACOG Committee Opinion No. 315. American College of Obstetricians and Gynecologists. Obstet Gynecol 2005;106:671–5. 6. Fetal monitoring prior to scheduled cesarean delivery. ACOG Committee Opinion No. 382. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:961–2. 7. Patient safety in the surgical environment. Committee Opinion No. 464. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:786–90. Standardization of health care processes and reduced variation has been shown to improve outcomes and quality of care. The American College of Obstetricians and Gynecologists has developed a series of patient safety checklists to help facilitate the standardization process. This checklist reflects emerging clinical, scientific, and patient safety advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Although the components of a particular checklist may be adapted to local resources, standardization of checklists within an institution is strongly encouraged. How to Use This Checklist The Patient Safety Checklist on Preoperative Planned Cesarean Delivery should be completed by the health care provider during the patient’s admission. Copyright December 2011 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Requests for authorization to make photocopies should be directed to: Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400. Preoperative planned cesarean delivery. Patient Safety Checklist No. 4. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:1471–2.

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