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OR SAMPLE CHARTING
CAESAREAN SECTION
TIME > Into OR a __ year old __________ per
wheelchair/stretcher accompanied by NOD & orderly
with ongoing IVF of __________ @ __________cc level
infusing well at _____ arm.
>Conscious & coherent
>With consent signed for C.S.
>Ushered to OR table in supine position
> Cardiac Monitor attached w/ preop V/S
BP=_____________mmHg PR=_____________BPM
RR=_____________CPM
SPO2=___________%
> O2 inhalation administered @ 2 LPM per nasal
cannula
>Repositioned to side lying with knees flexed
>Lumbar skin prepped done by NOD.
>Draped aseptically
TIME >Operation started wherein a midline incision was
done by
Dr. _________________ assisted by Dr. _________________
>Incision deepened to peritoneum
>Amniotic sac artificially ruptured and fluid suctioned
>Uterus incised
>Fetal head was delivered
TIME >Delivered an alive baby _______ in cephalic
presentation via C.S.
>Double clamping of umbilical cord then cut
>Immediate NB care rendered by Pediatrician Dr.
_____________
TIME >Placenta out complete in Schultz presentation
followed with thorough evacuation of uterine blood
clots.
>Uterine incision sutured by layer
>Bilateral Tubal Ligation done
TIME >Left fallopian out