OT notes · Obstetrics

Peripartum / caesarean hysterectomy

Usual anaesthesia
General (often converted from spinal); combined spinal-epidural for planned accreta surgery
Position
Supine with left lateral tilt; lithotomy preferred for planned accreta surgery
Setting
emergency

Operative note template for a peripartum or caesarean hysterectomy, with a filled example for an emergency subtotal hysterectomy for atonic postpartum haemorrhage at caesarean after conservative measures failed.

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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

  • loss of fertility and of periods (explain to patient and relative)
  • massive blood transfusion and blood product reactions
  • bladder injury
  • ureteric injury
  • bowel injury
  • need for intensive care and ventilation
  • coagulopathy and continued bleeding needing packing or re-laparotomy
  • thromboembolism
  • wound infection
  • death

Pre-operative details for this operation

  1. Indication for hysterectomyAtonic PPH not responding to conservative measuresPlacenta accreta spectrumUterine rupture not repairablePlacenta praevia with uncontrolled placental bed bleedingExtension / laceration into uterine vessels
  2. Measures tried before hysterectomyeach uterotonic with dose and time, massage, bimanual compression, tranexamic acid, balloon, compression suture, vessel ligation
  3. Estimated blood loss at time of decisionand haemodynamic status: pulse, BP, shock index
  4. Decision made by and timeconsultant name, second consultant opinion if taken, time
  5. Consentwho gave it (patient / relative), in which language, risks explained, time
  6. Blood and productsunits of PRBC, FFP, platelets, cryoprecipitate arranged and given; massive transfusion protocol activated
  7. Investigations sentHb, platelets, PT/INR, APTT, fibrinogen, cross-match, ABG / lactate
  8. Teams informedanaesthesia consultant, blood bank, ICU, urology / surgery backup

Anaesthesia and position

  1. AnaesthesiaGeneralConverted from spinal to generalCombined spinal-epidural (planned)time of conversion
  2. Access and monitoringtwo large-bore IV lines / central line, arterial line
  3. PositionSupine with left lateral tiltLithotomy
  4. Ureteric stents (planned accreta)Placed at cystoscopyNot placed

Operative findings

  1. Uterusatonic / ruptured (site and extent) / accreta (area, depth, bladder involvement)
  2. Placentasite, delivered or left in situ, adherent area
  3. Lower segment, cervix and vaginaextensions, tears, cervical involvement
  4. Broad ligaments / retroperitoneumNo haematomaHaematoma: side, size, expanding or not
  5. Bladderadherent, invaded, injured, intact on test
  6. Uretersseen, peristalsing, stents palpable
  7. Ovariesnormal / conserved / removed (reason)
  8. Oozing from raw surfaces (coagulopathy)NoYes

Procedure (steps)

  1. IncisionExisting caesarean incision reopened / usedMidline verticalPfannenstiel
  2. Temporary controlTourniquet (Penrose / catheter) round the isthmus through broad ligament windowsManual aortic compression (start and stop times)Pelvic packingNone
  3. Hysterotomy closed quicklySingle layerAlready closedNot closed, uterus clamped
  4. Round ligaments clamped, cut and ligatedboth sides; suture used
  5. AdnexaTubes and utero-ovarian ligaments clamped, ovaries conservedSalpingectomy doneOophorectomy (side and reason)
  6. Uterovesical peritoneum opened, bladder pushed downBluntSharpAfter retrograde filling of bladder
  7. Uterine vesselsskeletonised, doubly clamped close to the uterus, cut and suture ligated each side; ureters seen
  8. Type of hysterectomySubtotal (supracervical)Totalreason for choice
  9. Cervical stump or vaginal vault closuresuture and technique; how the cervico-vaginal junction was identified for total
  10. Checks at the endbladder filled / dye test, ureters seen, pedicles dry, broad ligaments
  11. Packing (if coagulopathy)number of packs left, plan for removal

Closure, drains and dressing

  1. DrainNonePelvic drain (type, size, side)
  2. Packs left in abdomenNoneYes: number, abdomen left open / temporarily closed
  3. Rectus sheathsuture and technique
  4. SkinSubcuticularInterruptedStaples
  5. Vaginal bleeding at endvagina checked from below
  6. Urine in cathetercolour, volume, haematuria

Specimens and implants

  1. Uterus (with or without cervix) for HPEnote subtotal / total, tubes / ovaries included, placenta in situ
  2. Placenta for HPESent separatelyIn situ in specimen
  3. Ureteric stentsRemoved at endLeft in situNot used

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. Shift to ICU / HDUventilated or extubated; handover to ICU team
  2. Vitals and bleedingpulse, BP, SpO2, urine output hourly; drain output; vaginal bleeding; abdominal girth
  3. Repeat investigationsHb, platelets, coagulation, fibrinogen, electrolytes including calcium and potassium, on arrival and after 4 to 6 hours
  4. Blood productsfurther units ordered and targets
  5. Catheterremove on POD 1 if uncomplicated; longer if bladder dissected or repaired
  6. Thromboprophylaxismechanical from OT; LMWH from 6 hours if no ongoing bleeding
  7. Antibioticsdrug, dose, duration
  8. Packs (if left)plan and time for re-look and removal
  9. Babylocation, breastfeeding when mother is able
  10. Debrief and counsellingexplain to patient and family what was done and why; record who was told

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. M.D., 31 years, G3P2L2 (two previous vaginal births), emergency LSCS at term for obstructed labour, with atonic PPH after delivery not controlled by oxytocin, carboprost, tranexamic acid and a B-Lynch suture, taken up for emergency subtotal hysterectomy.

Case details

Date: 22/08/2026. Emergency. Labour OT.

LSCS skin incision 21:10. Baby delivered 21:16. Decision for hysterectomy 22:05. Hysterectomy completed 23:05. Closure completed 23:30.

Surgeon: Dr C. (Consultant, OBGY). Assistants: Dr A. (3rd-year resident), Dr B. (2nd-year resident). Second consultant opinion: Dr F., present in OT from 21:55.

Anaesthetist: Dr D. (Consultant). Scrub nurse: Sr E.

Indication and pre-op

Atonic uterus after delivery of the placenta. Measures tried: oxytocin 5 IU slow IV at 21:17 then infusion 20 IU in 1000 ml RL; uterine massage and bimanual compression; carboprost 0.25 mg IM at 21:30 and 21:45; tranexamic acid 1 g IV over 10 min at 21:32; B-Lynch suture with chromic catgut No. 2 at 21:50. Uterus remained atonic with continued bleeding from the placental bed.

EBL 2500 ml at decision. Pulse 128/min, BP 84/50 mmHg.

Decision for hysterectomy by Dr C. and Dr F. at 22:05.

Consent for hysterectomy taken from husband in Marathi at 22:08 (patient under GA), risks including loss of fertility, ICU and death explained. Consent for LSCS had been taken earlier from the patient.

Massive transfusion protocol activated 21:40. Blood group B positive. Hb before surgery 10.2 g/dl. Coagulation profile, fibrinogen and ABG sent at 21:40.

ICU, blood bank and general surgery on-call informed.

WHO checklist done before the LSCS. Inj cefazolin 2 g IV at 21:02 before skin incision; second dose 2 g IV at 22:10 as blood loss exceeded 1500 ml.

Anaesthesia and position

Spinal anaesthesia for LSCS, converted to general anaesthesia with endotracheal intubation at 21:42 because of haemodynamic instability.

Two 16 G IV lines and a right radial arterial line. Supine with left lateral tilt.

Findings

Uterus soft and atonic despite the B-Lynch suture. Bleeding from the placental bed. Lower segment incision intact, no extension.

No broad ligament haematoma. Bladder normal. Both ureters seen at the pelvic brim, peristalsing.

Both ovaries normal, conserved.

Generalised oozing from raw surfaces towards the end.

Procedure

Pfannenstiel incision of the LSCS used. Hysterotomy already closed.

Penrose drain passed through windows in the avascular part of both broad ligaments at the isthmus, crossed and held with a clamp as a tourniquet at 22:10. Bleeding reduced.

Both round ligaments clamped, cut and ligated with No. 1 polyglactin 910 (Vicryl).

Tubes and utero-ovarian ligaments clamped, cut and double ligated on both sides, close to the uterus. Ovaries conserved.

Uterovesical peritoneum opened and bladder pushed down bluntly below the level of the uterine vessels.

Posterior leaf of the broad ligament opened on each side, ureters seen.

Uterine vessels skeletonised, doubly clamped close to the uterus at the isthmus, cut and doubly suture ligated on both sides.

Subtotal hysterectomy chosen: patient unstable, cervix effaced and no cervical bleeding. Uterus amputated above the level of the uterosacral ligaments at 23:05.

Cervical stump closed with interrupted figure-of-eight Vicryl No. 1.

Pedicles checked, dry. Bladder intact: urine clear. Ureters seen again on both sides.

Diffuse ooze from pelvic peritoneum controlled with pressure packing for 10 minutes while FFP and cryoprecipitate were given. No packs left inside.

Closure

14 Fr suction drain in the pelvis through a separate left-sided stab.

Parietal peritoneum not closed. Rectus sheath closed with continuous Vicryl No. 1. Skin closed with staples.

Vagina checked at the end: minimal bleeding. Urine clear, 150 ml since start.

Specimens and implants

Uterus (subtotal, without cervix) with both tubes, sent for HPE.

No implants.

End of procedure

Total estimated blood loss 3500 ml (suction 2200 ml + weighed mops and drapes).

Transfused: 6 units PRBC, 6 units FFP, 6 units platelets, 10 units cryoprecipitate. Inj calcium given by the anaesthetist as per ABG.

Mop, needle and instrument count correct, confirmed by scrub nurse.

Complication: massive PPH needing hysterectomy.

Shifted to ICU on ventilator at 23:45. Pulse 104/min, BP 102/64 mmHg on no vasopressor. Baby in NICU, stable.

Post-op orders

ICU care. Pulse, BP, SpO2, urine output and drain output hourly. Check abdomen and vaginal bleeding hourly.

Hb, platelets, PT/INR, APTT, fibrinogen, electrolytes and ABG on arrival and after 4 to 6 hours.

Mechanical calf compression from OT. LMWH from 6 hours after surgery if no further bleeding, dose as per ICU chart.

Catheter to stay; remove on POD 1 if urine clear.

Antibiotics as per unit protocol.

Family counselled by Dr C. at 23:50 about the hysterectomy and the reason for it.

Signature

Dr A., JR-3, OBGY, on behalf of Dr C. Reg. no. ________. 23/08/2026, 00:15.

Must document for this operation

  • Every measure tried before hysterectomy, with drug, dose and time. Maternal near-miss and hysterectomy audits, and courts, ask whether fertility-sparing steps were tried first.
  • Who made the decision, whether a second senior opinion was taken, and the time. Hysterectomy ends fertility, and the record must show it was a senior, timely decision.
  • Who gave consent, when, in what language, and that loss of fertility was explained. The patient is often under GA, so consent from a relative must be clearly recorded.
  • Subtotal or total, and whether ovaries were conserved. A cervical stump needs future cervical screening, and ovarian status decides hormone care.
  • Bladder and ureters checked at the end, and how. Urinary tract injury is the most common injury after bleeding, and the note shows it was looked for.
  • Blood loss and all blood products given, with units. Needed for transfusion audit, reactions and ICU care.
  • Start and stop times of aortic compression or tourniquet, and any packs left. Limb or organ ischaemia and retained packs are traced from these times and counts.

Common mistakes in these notes

  • Writing 'hysterectomy done for PPH' with no list of what was tried first.
  • No time of decision or name of the consultant who decided.
  • Not stating subtotal or total hysterectomy.
  • Not recording ovaries conserved or removed.
  • Leaving out transfusion details because the anaesthetist records them.
  • Not writing that packs were left in the abdomen and how many.

Indian practice and paperwork

  • 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)
  • In NQAS-assessed public hospitals, the OT checkpoint 'Operative Notes are Recorded' looks for the people present, pre- and post-op diagnosis, procedure, length of procedure, estimated blood loss, fluids given, specimen removed and complications. (NQAS Assessor's Guidebook for District Hospitals 2020, Vol I, ME E8.4)
  • Placenta is Yellow category (a) human anatomical waste under the Bio-Medical Waste Management Rules 2016; record whether it was sent for HPE or discarded. (CPCB/DGHS Guidelines under BMW Management Rules 2016)

Sources

  • Apuzzio JJ, Vintzileos AM, Berghella V, Alvarez-Perez JR, eds. Operative Obstetrics. 4th ed. CRC Press; 2017, Ch 22, Postpartum hemorrhage (Brown HL, Edwards J, Small M): peripartum hysterectomy; Ch 30, Cesarean delivery: cesarean hysterectomy, pp. 281, 289-290; 407-409.
  • Handa VL, Van Le L, eds. Te Linde's Operative Gynecology. 13th ed. Wolters Kluwer; 2024, Ch 44, Surgery for obstetric hemorrhage (Wright JD, Khoury-Collado F): general principles, tourniquet, packing, peripartum hysterectomy, post-op care, e-book PDF pp. 2302-2310, 2321-2337.
  • Arulkumaran S, ed. Best Practice in Labour and Delivery. 3rd ed. Cambridge University Press; 2026, Ch 16, Postpartum haemorrhage (tranexamic acid, carboprost, escalation to hysterectomy), pp. 198-200.
  • Operative Obstetrics 4e, Ch 22 Postpartum hemorrhage: p. 280 (oxytocin 5-10 IU slow IV, 10-40 IU in 1000 ml at 150 ml/h); p. 281 Table 22.3 (15-methyl PGF2 alpha 0.25 mg IM); p. 289 (B-Lynch with No. 2 absorbable suture).
  • Best Practice in Labour and Delivery 3e, Ch 16, p. 198 (tranexamic acid 1 g IV over 10 minutes), p. 199 (carboprost IM every 15 minutes, maximum eight doses).
  • Bratzler DW, et al. ASHP/IDSA/SIS/SHEA Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm 2013. Cesarean delivery: single dose of cefazolin before incision; Table 2 cefazolin 2 g; redose if blood loss exceeds 1500 ml. www.ashp.org/-/media/assets/policy-guidelines/docs/therapeutic-guidelines/therapeutic-guidelines-antimicrobial-prophylaxis-surgery.pdf

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.

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