OT notes · Obstetrics

Exploration of cervix and repair of cervical tear

Usual anaesthesia
IM sedation with local infiltration in the labour room for one or two small tears in a stable, cooperative woman; general anaesthesia in OT for heavy bleeding, multiple tears, extension to the fornix or severe pain
Position
Lithotomy
Setting
emergency

Operative note template for exploration of the cervix and vagina and repair of a cervical tear after vaginal delivery, with a filled example for a bleeding lateral cervical tear after a ventouse delivery, repaired in OT under general anaesthesia.

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

  • further bleeding and blood transfusion
  • tear found to extend into the lower segment of the uterus, needing laparotomy
  • injury to the ureter with a high lateral tear
  • vaginal or paravaginal haematoma after repair
  • infection
  • need for vaginal packing
  • cervical defect or scarring found later, rarely cervical weakness in a future pregnancy
  • hysterectomy if bleeding cannot be controlled

Pre-operative details for this operation

  1. Mode and time of deliverySpontaneous vaginalVentouseForcepsAssisted breechdate, time, any episiotomy
  2. Reason for explorationbleeding with a well-contracted uterus: amount, time noticed; or routine check after instrumental or precipitate delivery
  3. Placenta and membranesDelivered completeIncomplete / doubtful
  4. Uterine tone before explorationWell contractedAtonic
  5. Resuscitation startedtwo IV lines (size), oxytocin infusion, bladder catheter, cross-match sent, mop placed in vagina
  6. Vitals before shiftingpulse, BP, level of consciousness
  7. Hb and blood grouplast Hb, group, units cross-matched
  8. Previous cervical cerclage or cervical surgeryNoneCerclage (removed when)Other

Anaesthesia and position

  1. PlaceLabour roomOperation theatre
  2. AnaesthesiaIM sedation + local infiltrationGeneral anaesthesiaif GA, reason: heavy bleeding / multiple tears / fornix extension / pain
  3. PositionLithotomy
  4. BladderFoley catheter in situEmptied with simple catheter
  5. Light and helpgood light; number of assistants holding retractors

Operative findings

  1. Cervical tear(s)number, position by clock face, length in cm, bleeding or not
  2. Apex of tearSeen within vaginal cervixExtends to lateral fornixExtends above fornix / into lower segment
  3. Other cervical damageNoneCircular (annular) tearTorn-out portion after instrument
  4. Vaginal walls and fornicestears, site, length; colporrhexis
  5. Paraurethral area, episiotomy, perineumtears, degree of perineal tear
  6. HaematomaNoneVaginalVulvalBulge in fornix or parametrium
  7. Uterine tone at exploration

Procedure (steps)

  1. Perineum cleaned and drapedantiseptic used
  2. Clots removed from vagina, mop taken out and counted
  3. Vagina exposedTwo Sims speculumsBroad-bladed retractors (number)assistant holding
  4. Cervix held and inspected all roundSponge holders walked round the cervixRing forceps placed about 60 degrees apart round the whole cervixdirection of inspection: clockwise / anticlockwise
  5. Tear exposedcervix pulled to the opposite side and towards the introitus
  6. First stitch above the apexhow far above the apex; apex seen or not
  7. Cervical tear suturedInterruptedContinuous interlockingtechnique, suture material and size, e.g. interrupted rapid-absorbing polyglactin 910 (Vicryl Rapide) 2-0; number of sutures. Continuous and buttonhole sutures can be too tight and cause necrosis
  8. Second tear repaired (if any)position, length, sutures
  9. Vaginal / fornix tears repairedfrom the side towards the cervix, starting above the apex; suture used
  10. Paraurethral tears, episiotomy and perineum repaired last, from above downwardscatheter in place if paraurethral tear sutured
  11. Haemostasis checkedno bleeding from above the highest stitch
  12. Uterine cavity check (if bleeding persists or placenta doubtful)Not neededExplored manually: emptyRetained tissue removed
  13. Extension above the fornix or into lower segmentNot presentPresent: laparotomy done (separate note)

Closure, drains and dressing

  1. Vaginal packNonePack inserted (number of mops, time; remove within 24 h)
  2. Per rectal examinationDone: no suture through rectumNot needed
  3. Uterine tone and bleeding at end
  4. Urine in cathetercolour, haematuria?
  5. Mop and needle countinclude mops placed in the vagina before shifting

Specimens and implants

  1. SpecimenNoneRetained tissue sent for HPE

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. Vitals, uterine tone and PV bleedingfrequency as per the unit PPH protocol; chart every reading
  2. Oxytocin infusiondrug, dose, rate and when to stop
  3. Watch for haematomainform if pain in vagina, rectum or perineum, pressure on bladder, or falling BP without visible bleeding
  4. Vaginal pack removaltime, if a pack was placed; count the mops out
  5. Catheterfor a few days if a paraurethral tear was sutured; record urine output
  6. Hbtime of repeat Hb; transfusion plan
  7. Analgesiadrug, dose, frequency
  8. Postnatal checkinspect cervix and vagina at the postnatal visit for granulation or a cervical defect

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. P.K., 27 years, G2P2, delivered by ventouse at term for a prolonged second stage. Bleeding continued after complete delivery of the placenta with a well-contracted uterus.

Case details

Date: 14/07/2026. Emergency. OT 2.

Baby born 01:40 (ventouse, with right mediolateral episiotomy). Placenta out 01:48, complete. Bleeding noticed 01:55. Decision to explore in OT 02:05. In OT 02:15. GA induced 02:20. Procedure ended 02:55.

Surgeon: Dr A. (2nd-year resident, OBGY). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: continued bright red vaginal bleeding, about 500 ml in 10 min, with a well-contracted uterus after complete placenta. Bleeding hid the view in the labour room, so shifted to OT for exploration under GA.

In labour room: mop placed in vagina (1 mop). Two 18G IV lines. Oxytocin 20 IU in 1000 ml RL at 150 ml/h. Foley catheter, urine clear. Blood sent for cross-match.

Pulse 108/min, BP 104/66 mmHg, conscious and oriented. Hb 10.8 g/dl at admission. Blood group O positive, 2 units cross-matched.

No previous cerclage or cervical surgery.

Consent for exploration, repair, blood transfusion and laparotomy if needed taken in Marathi from patient, husband as witness. Anaesthesia consent by Dr D.

WHO checklist sign in and time out done. Antibiotic as per unit protocol (drug, dose and time on the anaesthesia chart).

Anaesthesia and position

General anaesthesia. Lithotomy. Perineum cleaned with povidone-iodine and draped. Foley catheter in situ.

Procedure

Vaginal mop removed (1 mop, counted). Clots removed. Uterus well contracted.

Vagina exposed with two Sims speculums held by Dr B. Anterior and posterior lips of cervix held with two sponge holders. Cervix inspected clockwise all round, sponge holders moved step by step.

Findings: left lateral cervical tear at 3 o'clock, 3 cm long, actively bleeding, apex seen within the vaginal part of the cervix, not reaching the fornix. Small tear at 9 o'clock, 1 cm, not bleeding. Left lateral vaginal wall tear 2 cm, separate from the episiotomy. No haematoma. Paraurethral area intact. Episiotomy intact with no extension.

Cervix pulled to the right and down to expose the 3 o'clock tear. First stitch taken above the apex. Tear closed with interrupted rapid-absorbing polyglactin 910 (Vicryl Rapide) 2-0, 4 sutures.

9 o'clock tear closed with 2 interrupted Vicryl Rapide 2-0 sutures.

Left vaginal wall tear closed with interrupted Vicryl Rapide 2-0, starting above the upper end.

Mediolateral episiotomy repaired in layers after all upper tears were closed: vaginal mucosa, then muscle, then skin.

No bleeding from above the highest stitch on any tear. Uterine cavity not explored as placenta was complete and uterus contracted.

Closure

No vaginal pack. Per rectal examination: no suture through the rectal wall.

Uterus well contracted at end. Minimal trickle only. Urine clear, 80 ml.

End of procedure

Estimated blood loss: 900 ml in total from delivery (600 ml before OT, 300 ml in OT, measured in drape and weighed mops). No transfusion in OT.

Mop, needle and instrument count correct, including the vaginal mop from the labour room.

No intra-operative complications. No specimen.

Extubated in OT. Shifted to recovery. Pulse 96/min, BP 110/70 mmHg.

Post-op orders

Pulse, BP, uterine tone and PV bleeding charted as per the unit PPH protocol.

Oxytocin infusion as above to complete.

Inform at once if pain in the vagina or rectum, urge to pass stool, or fall in BP without visible bleeding (haematoma).

Foley catheter to stay until bleeding has settled and she is fully awake. Record hourly urine output.

Repeat Hb, time as per unit protocol. Transfuse if Hb below the unit threshold or if symptomatic.

Inspect cervix and vagina at the postnatal visit.

Signature

Dr A., JR-2, OBGY. Reg. no. ________. 14/07/2026, 03:10.

Must document for this operation

  • Each tear by clock position, length and whether the apex was seen. If she bleeds again, the next doctor knows where to look; a missed apex is the usual source of a later haematoma.
  • That the whole circumference of the cervix was inspected, and how. Writing 'cervix explored' without saying it was seen all round does not stand up in an audit of postpartum haemorrhage (PPH).
  • Whether the tear reached the fornix or went above it. A tear above the fornix may be part of a uterine rupture and changes both the operation and the advice for the next pregnancy.
  • Suture material, technique and number of sutures. Continuous tight sutures can cause necrosis and a cervical defect; the postnatal examiner needs to know what was used.
  • Total blood loss from delivery, not only the loss in OT. PPH is graded on total loss, and transfusion decisions depend on it.
  • Mops placed in the vagina, and that they were removed and counted. A retained vaginal mop is a known cause of infection and a medicolegal claim.
  • Resuscitation given before and during the repair: IV lines, uterotonic, fluids, blood. This shows the bleeding was managed in the right order and supports the PPH audit.

Common mistakes in these notes

  • Writing 'cervical tear sutured' with no position, length or apex.
  • Not recording the tears that were found but left alone, or the areas that were normal.
  • Leaving out the episiotomy and vaginal tears repaired at the same sitting.
  • Forgetting to count out a vaginal pack or mop placed in the labour room.
  • Recording only the blood lost in OT, not the total since delivery.
  • Not writing why the repair was moved from the labour room to OT.

Indian practice and paperwork

  • Consent must be in a language the patient understands and taken by the person doing the procedure. The anaesthesia consent is taken by the anaesthetist. (NABH 5th ed., PRE.4(c) and (e), COP.13(d))
  • If a laparotomy becomes necessary for a tear going into the lower segment, state in the note whether it was covered by the written consent or was done because it was needed to save life and could not wait (Samira Kohli v. Dr Prabha Manchanda, Supreme Court, 2008). ((2008) 2 SCC 1)
  • Write the name of every anaesthetist in the note. A hospital was held negligent when the operation notes did not name the anaesthetist. (Thomas J. Indian J Urol 2009;25(3):384-8)
  • The operative note must be written before the patient leaves recovery. (NABH 5th ed., COP.14(e))

Sources

  • Apuzzio JJ, Vintzileos AM, Berghella V, Alvarez-Perez JR, eds. Operative Obstetrics. 4th ed. CRC Press; 2017, Ch 27, Maternal birth injuries (Ginath S, Golan A): vaginal lacerations, haematoma formation, cervical tears, pp. 360-363.
  • Podder AR, Seshadri JG. Atlas of Difficult Gynecological Surgery. Springer Nature Singapore; 2020, Ch 10, Traumatic postpartum hemorrhage: how to avoid and how to manage, pp. 170-174.
  • Operative Obstetrics 4e, Ch 22 Postpartum hemorrhage, p. 280 (oxytocin 10-40 IU in 1000 ml IV fluid at 150 ml/h) and p. 281 (bleeding not responding to massage and uterotonics calls for examination of vulva, vagina and cervix under adequate anaesthesia).

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.