Manual removal of placenta

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

• bleeding and need for blood transfusion
• incomplete removal and retained pieces needing further evacuation
• infection of the uterus (endometritis)
• uterine perforation or rupture
• uterine inversion
• placenta accreta found, with possible laparotomy or hysterectomy
• vaginal or cervical injury

Pre-operative details for this operation

1. Delivery detailsmode, time of birth of baby, gestation, parity, previous caesarean or uterine surgery
2. Third stage management so faruterotonic (drug, dose, route, time), second dose, controlled cord traction attempts, bladder emptied
3. Time since birth of babyretained if not delivered in 30 min with active management (60 min physiological)
4. Bleeding so far and vitalsmeasured loss, pulse, BP
5. InvestigationsHb, blood group, units cross-matched
6. Risk factors for accretaprevious caesarean, placenta praevia, previous curettage, previous MRP

Anaesthesia and position

1. AnaesthesiaSpinalEpidural top-upGeneral
2. PlaceOperation theatreLabour room
3. PositionLithotomy
4. IV access and oxytocin infusion ready

Operative findings

1. CervixOpenPartly closed (hand passed with gentle pressure)
2. Placenta stateSeparated, trapped in lower segment / cervixAdherent, separated with fingersNot separable: accreta suspected
3. Site of placental attachmentfundal / anterior / posterior / lateral / near scar
4. Placenta and membranes after removalcomplete / incomplete, missing cotyledons, vessels running to membrane edge (succenturiate lobe)
5. Uterine cavity after removalempty, walls intact, scar intact (if previous caesarean)
6. Genital tractcervical and vaginal tears seen?

Procedure (steps)

1. Asepsisantiseptic, elbow-length (gauntlet) glove
2. Bladder emptiedIn-out catheterFoley in situ
3. Prophylactic antibioticdrug, dose, time
4. Hand introduced along the cordfingers in a cone through the cervix; other hand holding the fundus throughout
5. Placental edge found and cleavage plane developedside-to-side movement of finger tips; placenta held in the palm
6. Uterine relaxant usedNoneNitroglycerindose, route, time
7. Placenta deliveredtime; removed in one piece / pieces
8. Cavity re-exploredEmptyPieces removed by handGentle curettage with large blunt curette
9. Uterotonic after removaldrug, dose, route; infusion rate; bimanual massage
10. If accreta suspectedNot applicableStopped, senior calledProceeded to laparotomyCord cut high, placenta left in situwho was called, time

Closure, drains and dressing

1. Uterine tone at endWell contractedBoggy: further measures
2. Vagina and cervix inspectedtears repaired, suture used
3. Vaginal packNonePack left: remove at (time)
4. Swab countCorrect

Specimens and implants

1. PlacentaSent for HPEDiscarded as yellow category wasteHanded to relatives with documentationreason for HPE, e.g. suspected accreta

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 vaginal bleedingevery 15 min for the first hour, then half-hourly till stable
2. Oxytocin infusiondose, rate, duration
3. CatheterFoley till sensation returns / remove at (time); measure urine output
4. BloodHb after 6 to 12 h; transfuse if ordered
5. Temperature and lochiawatch for fever or foul lochia (endometritis)
6. Placenta left in situ (if any)antibiotics, daily watch for bleeding and infection, senior plan
7. Future pregnancytell the woman that retained placenta can recur; deliver in a hospital

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