THEATRES & OPERATION NOTES

1. THEATRES &OPERATION NOTES Praneil Patel Obstetrics and Gynaecology

2. SURGICAL OPERATION NOTES Objectives • Theatre etiquette • Format of the operation note • Tips • Common procedures for ST1 level

3. THEATRE ETTIQUETTE • WHO check list • Introduce yourself to the team • Establishes risk • Enables Preparation

4. WHO CHECK LIST - OBSTETRICS

5. WHO CHECK LIST Surgery

6. SURGICAL OPERATION NOTES • Legal documentation • No formal training • Majority of operative notes are handwritten • Important source for medical records – legal and financial implications

7. ‘THE ADMIN’ Date of Procedure Patient details • Hospital sicker/hand write patient details Staff details • Operating Surgeon & grade • Surgical assistant & grade • Consultant overseeing care • Anaesthetist and grade

8. THE SURGERY AND THE REASON The full title of the operation carried out • List from major to minor • No abbreviations Type of anaesthetic used. Indication for the procedure – pre operative diagnosis i.e. 8/40 Missed Miscarriage with Vaginal Bleeding

9. ‘THE FINDINGS’ • VE &abdominal palpation findings • What was seen during the operation • Post operative diagnosis • Pathological findings • Any relevant negative findings? • As much detail as possible – site, size, colour, volume of structure involved • Picture aids • Any difficulties? • Blood Loss

10. ‘THE PROCEDURE’ Surgical steps • Position • Prepped and draped • Incision (what instrument you used) • Step by step description of surgical steps undertaken • Sutures used and type of suturing (locking, continuous) • Written justification of unusual steps • Drains in situ / catheter – what is draining at end of procedure • Any samples obtained – how you took them • Swabs, needles and instrument checked

11. POST OPERATIVE PLAN Important guidance on managing the patient in the post operative period Immediate • Analgesia • Medications • VTE assessment • Nutrition - fluids/ eating and drinking • Catheter management • Details of specific drains/dressing/packs/devices – when should they be removed • Samples for the lab • Routine post op care vs. close monitoring/ observations • Anaesthetic concerns

12. THE POST OPERATIVE PLAN Hospital Stay • Suture / Staples care • Blood tests • Specific nursing/midwifery instructions • Any specialist input needed e.g. physio • Patient debrief – plan for future e.g. next delivery/contraception • Discharge – when and by whom • Follow up

13. ‘THE SIGN OFF’ • Print your name [Stamp] • Sign the notes • Leave contact details

14. Thank you

15. Further Information Royal College of Surgeons of England - Guidelines for Clinicians on Medical Records and Notes (1994)

16. POSITION OF THE PATIENT Important medical legal detail • Appropriate position for access and to minimize complications e.g.. ulcers or nerve damage Common gynaecological patients’ positions

17. SURGICAL MANAGEMENT OF MISCARRIAGE ‘The admin’ ‘The surgery and the reason’ • Gestation • Rhesus status ‘The findings’ • VE – size of uterus, anteverted/retroverted, active bleeding, os open/closed • Size of suction curette used • Products seen • Haemostasis • EBL

18. SURGICAL MANAGEMENT OF MISCARRIAGE ‘The procedure’ • Lithotomy position • Prepped and draped • Intermittent catheterization • Cervix dilated – Hegar size • Easy vs. difficult dilatation • Size .... suction curettage used • Evacuation of products • Syntocinon given • Cavity checked – what with and by whom • EBL • Haemostasis achieved (contracted uterus)

19. SURGICAL MANAGEMENT OF MISCARRIAGE ‘The Post Operative Plan’ • Analgesia +/- • Medication – antibiotics, Anti D • Mobilize • E+D • Products – histology • +/- FBC • Monitor PVB loss • Debrief on the ward vs. nurse led discharge • Discharge • follow up ‘The sign off’

20. DIAGNOSTIC HYSTEROSCOPY ‘The admin’ ‘The surgery and the reason’ ‘The findings’ • VE • Vagina and vulva • Uterine size, position, masses, bleeding • Hysteroscopy • Cervical canal – easy/difficult entry • Utero-cervical length • Uterus – cavity/ endometrium/ fibroids/ polyps – location and size • Ostia • EBL

21. DIAGNOSTIC HYSTEROSCOPY ‘The Procedure’ • Dorsal Lithotomy position • Prepped and draped • Cervix dilated uterine • ?size of cavity • Normal saline hysteroscopy – hysteroscope inserted under direct vision • Any additional steps – polypectomy, curetting, resection • Repeat hysteroscopy following intervention ‘The Post Operative Plan’ • Analgesia • Mobilize • E+D • Monitor PV loss • Any biopsies/ tissue samples • Follow up plans ‘The sign off’

22. CAESAREAN SECTION The admin’ ‘The surgery and the reason’ • Category for Emergency LSCS • Indication for LSCS ‘The findings’ • Abdominal palpation • VE • Emergency LSCS – dilation, presentation, position, station • LSCS • Difficult or unusual steps • Adhesions • Abdominal cavity findings (signs of obstruction/ appearance of lower segment) • Presentation and position • Liquor • Placental delivery • EBL • Cord Gases

23. CAESAREAN SECTION ‘The Procedure’ • Supine position • Prepped and draped • Type of incision at skin • Entry into abdominal cavity • Bladder identified and reflected • Type of incision to lower segment • Delivery of baby – manual, forceps, any difficulty • Delivery of placenta • Uterine cavity check – empty • Uterine angles – any extension • Method of closure • Swabbing of vagina / uterus contracted

24. CAESAREAN SECTION ‘The Post Operative Plan’ • Analgesia – e.g. PR given • Medications – e.g. antibiotics, thromboprophylaxis, uterotonics • Catheter management • Details of specific drains/dressing/packs – when should they be removed • Suture care • Blood tests • Midwifery instructions • Patient debrief – plan for future e.g. next delivery/contraception ‘The sign off’