AHRQ Safety Program for Perinatal Care
Purpose of the tool: This tool describes the key perinatal safety elements related to safe cesarean section. The key elements are presented within the framework of the Comprehensive Unit-based Safety Program (CUSP).
Who should use this tool: Nurses, physicians, midwives, and other labor and delivery (L&D) unit staff responsible for intrapartum care.
How to use this tool: Review the key perinatal safety elements with L&D leadership and unit staff to determine how elements will be implemented on your L&D unit. Consider any existing facility policies, processes, or checklists related to cesarean section. Consider using preprinted checklists, laminated operating room posters, customized electronic health record tools, and staff simulation training to support implementation. An example of a safe cesarean section checklist is provided in the Appendix of this tool.
Key Perinatal Safety Elements
| Standardize When Possible (CUSP Science of Safety) | |
|---|---|
| Key Perinatal Safety Elements | Examples |
Use a standardized perioperative process for cesarean section that includes the following three elements:
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| Preoperative briefing |
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| Timeout prior to incision |
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| Signout and debrief |
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| Create Independent Checks (CUSP Science of Safety) | |
| Use cognitive aids such as a checklist to guide the safe surgery perioperative process. | Studies have demonstrated that safe surgery checklists can facilitate the safe surgery perioperative process.3-6
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| Learn From Defects (CUSP Module) | |
| Debrief and analyze adverse events related to cesarean section. |
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| Have a process in place to review severe maternal or neonatal morbidity and mortality events. |
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| Share outcomes or process improvements from the informal (debriefing) and formal analysis with staff to achieve transparency and organizational learning. | Sites can decide how often, how much, and with whom this information will be shared and whether this is specified in a unit policy or is handled more informally. |
| Simulation (SPPC Program Pillar) | |
Sample scenarios:
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| Teamwork Training (TeamSTEPPS®) | |
| Have situational awareness. | Situational awareness refers to all staff caring for the patient—
In the context of cesarean section, situational awareness refers to the use of briefings at critical junctures in care (preoperatively, prior to incision, at end of case prior to transfer to recovery); being aware of what is going on throughout the case; and anticipating what is to happen next. |
| Use SBAR (Situation, Background, Assessment, and Recommendation), callouts, huddles, and closed-loop communication techniques. | Use SBAR, callouts, huddles, and closed-loop communication among team members. In the context of cesarean section, these techniques are particularly useful—
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| Communicate during transitions of care. |
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| Foster a unit perspective of the safe cesarean section checklist as a tool for maximizing team performance, as opposed to a documentation requirement. |
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Have high-reliability teams:
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| Patient and Family Engagement (CUSP Module) | |
| Communicate risks and benefits of cesarean delivery with the patient and family. |
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| Disclose any unintended outcomes. | Use unit-established process for disclosing unintended outcomes. This may include the following:
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References
- Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009 Jan 29;360(5):491-9. PMID: 19144931.
- Russ S, Rout S, Sevdalis N, et al. Do safety checklists improve teamwork and communication in the operating room? A systematic review. Ann Surg 2013 Dec;258(6):856-71. PMID: 24169160.
- Agency for Healthcare Quality and Research’s Patient Safety Network. Patient Safety Primer on Checklists. 2012 October. http://psnet.ahrq.gov/primer.aspx?primerID=14. Accessed May 2, 2016.
- Hales B, Terblanche M, Fowler R, et al. Development of medical checklists for improved quality of patient care. Int J Qual Health Care 2008 Feb;20(1):22-30. PMID: 18073269.
- Physician-Patient Alliance for Health & Safety. 5 Benefits of Adopting Patient Safety Checklists. 2013 March 19. http://ppahs.org/2013/03/19/5-benefits-of-adopting-patient-safety-checklists/. Accessed May 2, 2016.
- Gawande AA. The Checklist Manifesto: How to Get Things Right. 1st ed., New York, NY: Metropolitan Books; 2009.
- World Health Organization. Patient Safety: Safe Surgery: Why Safe Surgery Is Important. 2014 http://www.who.int/patientsafety/safesurgery/en/. Accessed May 2, 2016.
Appendix
Every effort was made to ensure the accuracy and completeness of these resources. However, the U.S. Department of Health and Human Services makes no warranties regarding errors or omissions and assumes no responsibility or liability for loss or damage resulting from the use of information contained within.
Sample Checklist for Cesarean Delivery
A checklist for cesarean delivery serves as a guide for teams by including the key safety-related steps: preoperative briefing, timeout, and signout, as well as the timing and location as shown in the following figure:
This sample tool is based on the framework of the World Health Organization’s Surgical Safety Checklist, with adaptation for Cesarean Section.7
The Safe Cesarean Checklist for Planned/Routine Cesarean Sections is available in two formats: an "at a glance" format or a "large print" format. Examples of both formats have been included on the following pages. They both contain the same information. The "at a glance" format provides all information on one page. The "large print" format provides the same information across multiple pages using a clear, easy-to-read font. Hospital can review and adapt the contents and the format into whatever best meets unit needs.
At A Glance: Safe Cesarean Checklist for Planned/Routine Cesarean Section
| At the briefing station / nursing station | In operating room – Before skin incision | Before mother leaves the operating room |
|---|---|---|
| PREOP BRIEF (5 minutes) – Surgeon initiates | TIMEOUT (5 minutes) – Circulating nurse initiates when all staff present | SIGNOUT & DEBRIEF (2 minutes) – Circulating nurse initiates |
| Confirm/all participants present: ___ Anesthesia provider ___ Surgeon ___ First assistant ___ Resident physician (if applicable) ___ Patient’s labor and delivery (L&D) nurse ___ Circulating nurse ___ Charge nurse ___ Operating room (OR) technician ___ Pediatrics ___ Primary maternity provider (if other than surgeon) Team reviews: ___ Patient name ___ Patient date of birth ___ Patient informed of risks and benefits of C/S, patient and family questions answered ___ Consent signed (Yes / No) Procedure planned: ___ Cesarean section ___ Cesarean section with bilateral tubal ligation (BTL) ___ Other Indications for procedure: ___ Scheduled repeat C/S ___ Arrest of dilation ___ Arrest of descent ___ Nonreassuring Fetal Heart Rate Tracing (NRFHRT) ___ Malpresentation ___ Other_________________ Pertinent medical history: ___ Previous abdominal surgeries/Cesarean section (Yes/No) ___ Allergies (Yes/No) - If Yes, then list allergy and reaction ___ Group B strep status (Positive / Negative / Unknown) Fetal status: ___ Chorioamnionitis (Yes / No / Unknown) ___ Meconium (Yes / No / Unknown) Type of anesthesia planned: ___ Spinal ___ Epidural ___ Combined ___ General ___Blood products needed / anticipated? (Yes/No) Planned start / incision Time: ____:____ AM/PM |
Purpose of time out explained to patient if alert ("we are following a checklist to ensure your safety") All staff introduce themselves: ___ Anesthesia provider ___ Surgeon ___ First assistant ___ Resident physician (if applicable) ___ Patient’s L&D nurse (if applicable) ___ Circulating nurse ___ OR technician ___ Pediatric provider Circulating nurse verbalizes: ___ Identity (patient name & date of birth) Procedure planned: ___ Cesarean section ___ Cesarean section with BTL ___ Other Indications for procedure: ___ Scheduled repeat C/S ___ Arrest of dilation ___ Arrest of descent ___ NRFHRT ___ Malpresentation ___ Other ______________ ___ Cord blood collection (Yes/No) ___ Consent signed & on chart (Yes/No) ___ Fetal tracing status (Category I / Category II / Category III) ___ Allergies (Yes/No) If yes, specify __________________ ___ Patient positioned (Lateral displacement done / Vaginal hand needed? (Yes/No) ___ Pneumatic compression stockings on (Yes/No) ___ Grounding pad applied (Yes/No) ___ Foley catheter in (Yes/No) Surgeon confirms: ___ Expected duration of procedure ___ Should blood be available in the room for this case? (Yes/No anticipated)* If yes, then make preparations if not already available) ___ Additional instruments needed / anticipated (Yes/No) Anesthesia provider confirms: ___ Type of anesthesia used (Spinal / Epidural / Combined / General) ___ Antibiotics infused within 60 minutes of incision time (Yes/No) ___ Anesthesiology concerns (Yes/No) If yes, specify _____________ Pediatric provider confirms: ___ GBS status (Positive / Negative / Unknown) ___ Meconium (Yes/No / Unknown) ___ Chorioamnionitis (Yes/No / Unknown) ___ Pediatric concerns (Yes/No) If yes, specify _____________ |
Items reviewed: Procedure performed ___ Cesarean section ___ Cesarean section with BTL ___ Other ____________ ___ Antibiotics infused within 60 minutes of incision time (Yes/No) If No, consider administration of antibiotics ___ Sponge/needle / instrument counts correct (Yes/No) ___ Cord gases labeled (Yes/NA) ___ Specimens labeled (Yes/NA) ___ Deep vein thrombosis (DVT) prophylaxis planned ___ Sequential compression devices (SCDs) only ___ SCD+prophylactic heparin ___ SCD+adjusted dose heparin ___ N/A ___ Any equipment issues* (Yes/No) If yes list here: ___________________ ___________________ ___ Any system issues* (Yes/No) If yes list here: ___________________ ___________________ Postoperative concerns/issues for the team to be aware of? (Each team member listed below either says "Yes" and states the issues or says "No Concerns" if none) ___ Surgeon ___ Nurse ___ Anesthesia provider ___ Pediatric provider *Any equipment/systems issues identified should be recorded and provided to designated person so they can be addressed and resolution shared with the unit. |
At A Glance: Safe Cesarean Checklist for Urgent/Emergency Cesarean Sections
| At the briefing station / nursing station | In operating room – Before skin incision | Before mother leaves the operating room |
|---|---|---|
| PREOP BRIEF – Not performed | TIMEOUT (5 minutes) – Circulating nurse initiates ONLY if appropriate for the level of maternal/fetal distress and clinical situation | SIGNOUT & DEBRIEF (2 minutes) – Circulating nurse initiates |
| N/A | Purpose of time out explained to patient if alert ("we are following a checklist to ensure your safety") All staff introduce themselves: ___ Anesthesia provider ___ Surgeon ___ First assistant ___ Resident physician (if applicable) ___ Patient’s L&D nurse (if applicable) ___ Circulating nurse ___ OR technician ___ Pediatric provider Circulating nurse verbalizes: ___ Identity (patient name & date of birth) Planned procedure: ___ Cesarean section ___ Cesarean section with bilateral tubal ligation (BTL) ___ Other Indications for procedure: ___ Arrest of dilation ___ Arrest of descent ___ Malpresentation ___ Nonreassuring Fetal Heart Rate Tracing / fetal distress ___ Maternal distress ___ Other ______________ ___ Consent signed & on chart (Yes/No) ___ Cord blood collection (Yes/No) ___ Fetal tracing status (Category I / Category II / Category III) ___ Allergies (Yes/No) If yes, specify __________________ ___ Patient positioned (Lateral displacement done / Vaginal hand needed? (Yes/No) ___ Pneumatic compression stockings on (Yes/No) ___ Grounding pad applied (Yes/No) ___ Foley catheter in (Yes/No) Surgeon confirms: ___ Expected duration of procedure ___ Should blood be available in the room for this case? (Yes/No anticipated)* If yes, then make preparations if not already available) ___ Additional instruments needed / anticipated (Yes/No) Anesthesia provider confirms: ___ Type of anesthesia used (Spinal / Epidural / Combined / General) ___ Antibiotics infused within 60 minutes of incision time (Yes/No) ___ Anesthesiology concerns (Yes/No) If yes, specify _____________ Pediatric provider confirms: ___ GBS status (Positive / Negative / Unknown) ___ Meconium (Yes/No / Unknown) ___ Chorioamnionitis (Yes/No / Unknown) ___ Pediatric concerns (Yes/No) If yes, specify _____________ |
Items reviewed: Procedure performed ___ Cesarean section ___ Cesarean section with BTL ___ Other ____________ ___ Antibiotics infused within 60 minutes of incision time (Yes/No) If No, consider administration of antibiotics ___ Sponge/needle / instrument counts correct (Yes/No) ___ Cord gases labeled (Yes/NA) ___ Specimens labeled (Yes/NA) ___ Deep vein thrombosis (DVT) prophylaxis planned ___ Sequential compression devices (SCDs) only ___ SCD+prophylactic heparin ___ SCD+adjusted dose heparin ___ N/A ___ Any equipment issues* (Yes/No) If yes list here: ___________________ ___________________ ___ Any system issues* (Yes/No) If yes list here: ___________________ ___________________ Postoperative concerns/issues for the team to be aware of? (Each team member listed below either says "Yes" and states the issues or says "No Concerns" if none) ___ Surgeon ___ Nurse ___ Anesthesia provider ___ Pediatric provider *Any equipment/systems issues identified should be recorded and provided to designated person so they can be addressed and resolution shared with the unit. |
Safe Cesarean Checklist for Planned/Routine Cesarean Section
Detailed Preoperative Briefing Checklist
(5 minutes)
Who: Surgeon initiates
When: Before operating room (OR), after decision to proceed with cesarean section (C/S) is made
Where: Briefing station/nursing station
Confirm/all participants present:
___ Anesthesia provider
___ Surgeon
___ First assistant
___ Resident physician (if applicable)
___ Patient’s labor and delivery nurse
___ Circulating nurse
___ Charge nurse
___ Operating room (OR) technician
___ Pediatric provider
___ Primary maternity provider (if other than surgeon)
Team reviews:
___ Patient name
___ Patient date of birth
___ Patient informed of risks and benefits of C/S, patient and family questions answered
___ Consent signed (Yes / No)
Procedure planned:
___ Cesarean section
___ Cesarean section with bilateral tubal ligation
___ Other ______________________________
Indications for procedure:
___ Scheduled repeat C/S
___ Arrest of dilation
___ Arrest of descent
___ Nonreassuring fetal heart rate tracing
___ Malpresentation
___ Other_______________________________
Pertinent medical history:
Previous abdominal surgeries/cesarean section:
___ Yes
___ No
Allergies:
___ Yes. If Yes, specify _______________________________
___ No
Group B strep status:
___ Positive
___ Negative
___ Unknown
Fetal status:
Chorioamnionitis:
___ Yes
___ No
___ Unknown
Meconium:
___ Yes
___ No
Type of anesthesia planned:
___ Spinal
___ Epidural
___ Combined
___ General
Blood products needed/anticipated?
___ Yes
___ No
___ Unknown)
Planned start/incision time:
______:______ ___ AM ___PM
Detailed Timeout Checklist
(5 minutes)
Who: Circulating nurse initiates when all staff are present
When: Before skin incision
Where: In operating room (OR)
All staff introduce themselves:
___ Anesthesia provider
___ Surgeon
___ First assistant
___ Resident physician (if applicable)
___ Patient’s labor and delivery nurse
___ Circulating nurse
___ OR technician
___ Pediatric provider
Circulating nurse verbalizes:
Identity:
___ Patient name ___ Patient date of birth
Planned operation:
___ Cesarean section
___ Cesarean section with bilateral tubal ligation
___ Other ______________________________
Indications for procedure:
___ Scheduled repeat cesarean section
___ Arrest of dilation
___ Arrest of descent
___ Nonreassuring fetal heart rate tracing
___ Malpresentation
___ Other__________________________________
Consent signed & on chart:
___ Yes ___ No
Cord blood collection:
___ Yes ___ No
Fetal tracing status:
___ Category I
___ Category II
___ Category III
Allergies
___ Yes ___ No. If Yes, specify _______________________________
Patient positioned
___ Lateral displacement done
Vaginal hand needed ___ Yes ___ No
Pneumatic compression stockings on
___ Yes ___ No
Grounding pad applied
___ Yes ___ No
Foley catheter in
___ Yes ___ No
Surgeon confirms:
Expected duration of procedure: _______________________________
___ Should blood be available in the room for this case? ___ Yes, anticipated* ___ No
*If yes, then make preparations if not already available
Additional instruments needed/anticipated:
___ Yes ___ No
Anesthesia provider confirms:
Type of anesthesia used:
___ Spinal
___ Epidural
___ Combined
___ General
Antibiotics infused within 60 minutes of incision time:
___ Yes ___ No
Anesthesia provider concerns:
___ Yes ___ No. If yes, specify ______________________________
Pediatric provider confirms:
Group B strep status:
___ Positive
___ Negative
___ Unknown
Meconium:
___ Yes
___ No
Chorioamnionitis:
___ Yes
___ No
___ Unknown
___ Pediatric concerns:
___ Yes ___ No. If yes, specify ______________________________
Detailed Signout & Debrief Checklist
(2 minutes)
Who: Circulating nurse initiates
When: Before patient leaves operating room
Where: In operating room
Items reviewed:
Procedure performed:
___ Cesarean section
___ Cesarean section with bilateral tubal ligation
___ Other ______________________________
Antibiotics infused within 60 minutes of incision time:
___ Yes ___ No. If No, consider administration of antibiotics
Sponge/needle / instrument counts correct:
___ Yes
___ No
Cord gases labeled:
___ Yes
___ NA
Specimens labeled:
___ Yes
___ NA
Deep vein thrombosis prophylaxis planned:
___ Sequential compression devices (SCDs) only
___ SCD+prophylactic heparin
___ SCD+adjusted dose heparin
___ N/A
Any equipment issues:
___ Yes
___ No
*If yes list here:
____________________________________________________________________________
____________________________________________________________________________
Any system issues
___ Yes
___ No
*If yes list here:
____________________________________________________________________________
____________________________________________________________________________
*Any equipment/systems issues identified should be recorded and provided to designated person so they can be addressed and resolution shared with the unit.
Postoperative concerns/issues for the team to be aware of?
(Each team member listed below either says "Yes" and states the issues or says "No Concerns" if none)
Surgeon
___ Yes ____________________________________________________________________________
___ No concerns
Nursing
___ Yes ____________________________________________________________________________
___ No concerns
Anesthesia provider
___ Yes ____________________________________________________________________________
___ No concerns
Pediatric provider
___ Yes ____________________________________________________________________________
___ No concerns
