OT notes · Gynaecology

Dilatation and curettage / endometrial sampling

Usual anaesthesia
Paracervical block with sedation, or short general or spinal anaesthesia
Position
Dorsal lithotomy
Setting
elective

Operative note template for diagnostic dilatation and curettage (non-pregnancy indication) or endometrial sampling, with a filled example for a D&C in a perimenopausal woman with abnormal uterine bleeding.

Download printable PDFFree. Just log in with your Google (Gmail) account.

Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • uterine perforation
  • injury to bowel or blood vessels if perforation occurs, needing laparoscopy or laparotomy
  • bleeding
  • cervical tear or false passage
  • infection (uncommon)
  • intrauterine adhesions
  • sample may not be enough for diagnosis, or may miss a focal lesion
  • need for further procedure such as hysteroscopy

Pre-operative details for this operation

  1. Indicatione.g. AUB with failed or inadequate office biopsy, postmenopausal bleeding, thick endometrium on USG; not pregnancy-related
  2. USG findingsendometrial thickness in mm, polyp, fibroid, uterine size and position
  3. Pregnancy excludedLMP, urine pregnancy test
  4. Anticoagulants / bleeding disorderNoneOn anticoagulant (drug, INR if warfarin, plan)
  5. Cervical primingNot givenMisoprostol (dose, route, time)
  6. Pelvic infection excludedno purulent discharge, no uterine or adnexal tenderness

Anaesthesia and position

  1. AnaesthesiaParacervical block with sedationParacervical block aloneSpinalGenerallocal anaesthetic drug, concentration and volume
  2. PositionDorsal lithotomy, legs padded at fibular head
  3. BladderEmptied before OTCatheterised

Operative findings

  1. Examination under anaesthesiauterus size, position (AV / RV / axial), mobility; adnexa
  2. Cervixhealthy / erosion / polyp / scarred / stenotic os
  3. Uterine sound length (cm) and direction
  4. Curettingsamount (scanty / moderate / copious), appearance (normal / polypoidal / friable / cheesy)
  5. Cavity feelsmooth / irregular / submucous bulge

Procedure (steps)

  1. Painting and drapingantiseptic for vulva, vagina and cervix
  2. Speculum and exposureSims speculum with anterior vaginal wall retractorGraves speculum
  3. Cervix heldSingle-tooth tenaculum on anterior lipAllis / multi-tooth tenaculumPosterior lip
  4. Paracervical blocksites, drug, volume (if used)
  5. Uterus soundeddirection and length in cm
  6. Cervical dilatationHegarPrattup to which size; stenosis managed how
  7. CurettageSharp curette, all walls systematicallySuction cannulaPipelle / aspiration device onlycurette size; tissue collected on gauze in posterior fornix
  8. Polyp forceps passedNot doneDone: polyp removed / nothing found
  9. Haemostasistenaculum puncture sites checked; bleeding at end

Closure, drains and dressing

  1. Vaginal packNonePlaced (remove when)
  2. Bleeding at end of procedureMinimalMore than expected: action

Specimens and implants

  1. Endometrial curettings sent for HPEin formalin, with clinical details, LMP, hormone use
  2. Separate labelled containerendocervical curettings or polyp, if taken separately

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Vitalspulse and BP every 15 min till awake, then hourly till discharge
  2. Vaginal bleedingpad check; report heavy bleeding
  3. Watch for vasovagal reactionlight-headedness, sweating, nausea: keep supine, check BP
  4. Watch for perforation signsabdominal pain, distension, rising pulse, falling BP
  5. AnalgesiaNSAID for cramps, if no contraindication
  6. Oral intake and dischargeoral fluids when awake; discharge the same day once passed urine and walking
  7. Anticoagulantwhen to continue or restart, if on one
  8. Follow-upwith HPE report, date

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mrs. K.M., 47 years, P3L3, with heavy irregular bleeding for 6 months. TVS: uterus 8 x 5 cm, endometrium 16 mm, no fibroid. Office Pipelle sample inadequate. Urine pregnancy test negative. Hb 9.8 g/dl.

Case details

Date: 22/08/2026. Diagnostic D&C (day care). Minor OT.

In OT 11:00. Block 11:10. Procedure 11:14 to 11:26.

Surgeon: Dr A. (2nd-year resident, OBGY), supervised by Dr B. (Assistant Professor). Anaesthetist: Dr C. Scrub nurse: Sr D.

Indication and pre-op

Indication: perimenopausal abnormal uterine bleeding with thick endometrium (16 mm) and inadequate office sample. Not pregnancy-related.

Not on anticoagulants. No bleeding disorder. No signs of pelvic infection. No cervical priming.

Consent in Hindi for D&C, explaining perforation, bleeding and possible need for further procedure.

WHO checklist sign in and time out done. Antibiotic prophylaxis not given: not recommended for D&C for non-pregnancy indications.

Anaesthesia and position

IV sedation by anaesthetist (drugs and doses on anaesthesia record) with paracervical block. Dorsal lithotomy, legs padded. Passed urine before OT.

Vulva, vagina and cervix painted with povidone-iodine and draped.

Procedure

EUA: uterus 8 weeks, anteverted, mobile. Both fornices free.

Sims speculum and anterior vaginal wall retractor. Cervix healthy, os parous. Anterior lip held with single-tooth tenaculum.

Paracervical block: 1% lignocaine 10 ml at 2, 4, 8 and 10 o'clock at the cervicovaginal junction, after aspiration.

Uterus sounded to 8 cm, anteverted direction.

Cervix dilated with Hegar dilators from 3 to 7 mm.

Sharp curettage with Sims curette No. 1 over all walls, fundus and both cornua, tissue collected on gauze in the posterior fornix. Curettings moderate in amount, soft, no friable or cheesy tissue. Cavity smooth, no submucous bulge felt.

Polyp forceps passed: no polyp.

Tenaculum removed, puncture sites dry. Minimal bleeding from os at end.

Specimens

Endometrial curettings sent for HPE in formalin, with LMP, age and history of AUB on the requisition.

End of procedure

Blood loss about 20 ml. No perforation. Instrument and gauze count correct. No vaginal pack.

Shifted to recovery in stable condition. Pulse 84/min, BP 124/80 mmHg.

Post-op orders

Pulse, BP and pad check every 15 min till fully awake, then hourly.

Report pain in abdomen, distension, rising pulse or heavy bleeding.

Oral fluids when awake. NSAID for cramps if no contraindication, as charted.

Discharge in the evening if passed urine, walking and bleeding minimal. Oral iron to continue.

Review in gynaecology OPD with HPE report on 05/09/2026.

Signature

Dr A., JR-2, OBGY. Reg. no. ________. 22/08/2026, 11:40.

Must document for this operation

  • Indication and that the procedure was not pregnancy-related. A D&C for termination of pregnancy comes under the MTP Act, with its own forms and register, and must not be recorded as a diagnostic D&C.
  • Uterine position and sound length. If a perforation is suspected later, this shows how the instruments were passed and helps the next surgeon.
  • Amount and appearance of the curettings. Scanty tissue suggests the curette did not pass the internal os or a false passage, and friable tissue warns the pathologist and the clinician.
  • Any suspected perforation, where (fundal or lateral), and what was done. Management and follow-up differ by site, and a missed perforation with bowel injury is a medicolegal risk.
  • Anticoagulant status and plan. The ward team needs to know whether to continue or restart it.
  • Specimen labelled and sent with clinical details. The pathologist reads endometrium differently by age, LMP and hormone use.

Common mistakes in these notes

  • Writing 'D&C done, curettings sent' with no sound length or description of tissue.
  • Not recording that pregnancy was excluded.
  • No mention of cervical stenosis or difficult dilatation when it happened.
  • Leaving out the local anaesthetic dose in a procedure under paracervical block.
  • Sending the specimen without LMP and clinical details.

Indian practice and paperwork

  • If the curettage is for termination of pregnancy, the MTP Act rules apply: the RMP opinion form (Form I up to 20 weeks), the woman's consent (Form C) and an entry in the Admission Register (Form III), which records the method of MTP (MVA / EVA / MMA / D&C / others). Write that note as an MTP note, not a diagnostic D&C. (MTP Rules 2003 (amended 2021) and MTP Regulations 2003)
  • NABH standard COP.14(e) (5th edition) requires the operative note to be written before the patient is transferred out of recovery. (NABH Hospital Accreditation Standards 5th ed. (April 2020), COP.14 OE e)
  • Tissue not sent for HPE is Yellow category (a) human anatomical waste under the Bio-Medical Waste Management Rules 2016; record where the specimen went. (CPCB/DGHS Guidelines under BMW Management Rules 2016)

Sources

  • Handa VL, Van Le L, eds. Te Linde's Operative Gynecology. 13th ed. Wolters Kluwer; 2024, Ch 14, Dilation and curettage (Burkman RT, Sankey HZ); Ch 2, Table 2.4 antimicrobial prophylaxis, e-book PDF pp. 711-737; 164.
  • Te Linde's Operative Gynecology 13e, Ch 14: prophylactic antibiotics not required for endometrial sampling or D&C (pdf 715, 735); paracervical block 10 to 20 ml of 1% lidocaine around the cervix at the cervicovaginal junction or at 2, 4, 8 and 10 o'clock (pdf 716); misoprostol 400 microgram orally several hours before for suspected stenosis (pdf 726).
  • Te Linde's Operative Gynecology 13e, Ch 2, Table 2.4 (reprinted from ACOG Practice Bulletin 195, 2018): D&C for non-pregnancy indications and endometrial biopsy, antibiotic prophylaxis not recommended.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

This page cannot be printed from the browser. Use the Download printable PDF button on the page.