Date______________ Patient ______________________________ Date of birth__________ MR #_____________ Physician or certified nurse–midwife______________________________ Last menstrual period__________________ Gravidity/Parity____________________________ Estimated date of delivery________________ Best estimated gestational age (at admission)_______________ Proposed cesarean delivery date___________ Indication (choose one): ❏ Medically indicated: Diagnosis:_______________________________________________ ❏ Repeat cesarean delivery (choose one) (1, 2): ❏ Trial of labor not appropriate: Reason:______________________________________ ❏ Trial of labor offered ❏ Yes ❏ No: Reason:____________________________________ ❏ Patient counseled about risks and benefits of cesarean delivery versus trial of labor and vaginal delivery (1, 3) ❏ Consent form signed as required by the institution ❏ Repeat cesarean delivery for logistical reasons: Circumstances:_________________________________ ❏ Elective primary cesarean delivery at maternal request (4): ❏ Patient counseled about risks and benefits of cesarean delivery versus vaginal delivery (1, 3) ❏ Consent form signed as requested by institution ❏ Gestational age of 39 0/7 weeks or greater confirmed by either of the following criteria (5): ❏ Ultrasound measurement at less than 20 weeks of gestation supports gestational age of 39 weeks or greater ❏ Fetal heart tones have been documented as present for 30 weeks of gestation by Doppler ultrasonography If this is an elective cesarean delivery and gestational age is 39 0/7 weeks or less, reason for variance: Results of amniocentesis (if performed):___________________________________________________________ ❏ Preoperative and pertinent prenatal laboratory test results (eg, group B streptococci or hematocrit) available (2) ❏ Special concerns (eg, allergies, medical problems, and special needs)__________________________________ ❏ Pertinent comorbid risk factors (maternal and fetal)________________________________________________ To be completed by reviewer: ❏ Approved cesarean delivery for gestational age equal to or greater than 39 0/7 weeks by the afore- mentioned dating criteria ❏ Approved cesarean delivery before 39 0/7 weeks of gestation (medical indication) ❏ HARD STOP – gestational age, indication, consent, or other issues prevent initiating planned cesarean delivery without further information or consultation with department chair The American College of Obstetricians and Gynecologists Women’s Health Care Physicians ✓ Patient Safety Checklist SCHEDULING PLANNED CESAREAN DELIVERY Number 3 • December 2011 References 1. Vaginal birth after cesarean delivery. Practice Bulletin No. 115. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:786–90. 2. 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. 3. Surgery and patient choice. ACOG Committee Opinion No. 395. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;111:243–7. 4. Cesarean delivery on maternal request. ACOG Committee Opinion No. 394. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1501. 5. Fetal lung maturity. ACOG Practice Bulletin No. 97. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;112:717–26. 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 Scheduling Planned Cesarean Delivery should be completed by the health care provider and submitted to the respective hospital to schedule a planned cesarean delivery. The hospital should establish procedures to review the appropriateness of the scheduling based on the information contained in the checklist. A hard stop should be called if there are questions that arise that require further information or consultation with the department chair. 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. Scheduling planned cesarean delivery. Patient Safety Checklist No. 3. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:1469–70.

American College of Obstetricians and Gynecologists
409 12th Street SW, Washington, DC  20024-2188