Caesarean Section operative notes
Purpose
To record details about a Caesarean section operation
For recording operative details of caesarian section
Not for recording surgery other than Caesarian section
To record details about a Caesarean section operation
For recording operative details of caesarian section
Not for recording surgery other than Caesarian section
| Archetype Id | openEHR-EHR-COMPOSITION.report.v1 |
| Template ID | 54694d8e-5737-425b-a72e-e3c1da2efd14 |
| NHS CFH Care Record Element | Care Professional Documentation |
| Business Process Level | Operation: Caesarian section |
| User roles | Obstetrician |
| Owner | CFH NHS England |
| Specialty | Obstetrics |
| Care setting | Acute |
| Client group | Pregnant women |
| Sign off | CFH NHS England |
| Copyright | Crown |
| Acknowledgements | |
| Issues |
Report [+/-] 
Request details [0..1]
Request identifier [0..*]
Requesting clinician [0..1]
Contact details of requesting clinician [0..1]
Date of request [0..1]
[+/-] Report details [0..1]
Report identifier [0..*]
Status [0..1]
Date/time report issued [0..1]
[+/-] Copies to [0..1]
Copied party details [0..*]
[+/-] Referrals [0..1]
Referred party details [0..*]
Caesarian section notes [0..*] Caesarian consent [0..*] 
Consent caesarian section [0..*] Caesarian procedure information [0..*] Caesarian section description v4 [0..*] [+/-] description [1]
Class of Caesarian [0..1]
[+/-] Indication for elective [0..1]
Indication for Elective Caesarian [0..1] OR
OR
Other indicaion for elective caesarian [0..1]
[+/-] Indication for emergency [0..1]
Indication for Emergency Caesarian [0..1] OR
Other indication for emergency caesarian [0..1]
Date and time of Class 1 / 2 / 3 decision [0..1]
Time decision discussed with Consultant [0..1]
Consultant identification [0..1]
Expected number of babies [0..1]
[+/-] Time to theatre [0..1]
Date and time of transfer to theatre [0..1]
If emergency and more than 30 minutes, reason for delay [0..1]
[+/-] Personnel [0..1]
Operator identification [0..1]
Operator grade [0..1]
Assistant identification [0..1]
Assistant grade [0..1]
Anaesthetist identification [0..1]
Anaesthetist grade [0..1]
Consultant present in theatre? [0..1]
[+/-] Anaesthetic summary [0..1]
Type of anaesthetic or analgesic [0..1]
Other anaesthetic or analgesic [0..1]
Time anaesthetic commenced [0..1]
Time anaesthetic completed [0..1]
Number of failed attempts at analgesia [0..1]
Urinary catheter in situ? [0..1]
[+/-] If catheter not in situ [0..1]
Urinary catheter sited? [0..1]
Type of catheterisation [0..1]
[+/-] Uterus and cervix exams, if needed [0..1]
[+/-] Knife to skin [0..1]
Time knife to skin [0..1]
If emergency and more than 20 minutes from theatre arrival, reason for delay [0..1]
[+/-] Procedure details [0..1]
Type of skin incision [0..1]
Other skin incision [0..1]
Diagram description of incision [0..1]
[+/-] Abdominal cavity findings [0..1]
Adhesions? [0..1]
Adhesions site [0..1]
Adhesions degree [0..1]
Other comments [0..1]
Bladder reflected? [0..1]
Details of any difficulties with dissection [0..1]
[+/-] Infusion [0..*]
Fluid type [0..1] OR
Other fluid type [0..1]
Amount [0..1]
[+/-] Prophylactics [0..1]
[+/-] Prophylactic antibiotic [0..1]
Prophylactic antibiotic given [0..1]
Antibiotic comments [0..1]
Reason, if not given [0..1]
[+/-] Thromboprophylaxis [0..1]
Thromboprophylaxis considered [0..1]
Reason, if not considered [0..1]
Thromboprophylaxis given [0..1]
Thromboprophylaxis given [0..1]
Other thromboprophylaxis [0..1]
[+/-] Uterine incision [0..1]
Time knife to uterus [0..1]
Incision location [0..1] OR
Other incision location [0..1]
Incision type [0..1] OR
Other incision type [0..1]
Incision extent / angle [0..*] OR
Other extent / angle [0..1]
[+/-] Delivery of baby (per baby) [0..*]
Type of delivery [0..1]
[+/-] Closures [0..1]
[+/-] Uterine closure [0..1]
Uterine closure type [0..1]
Suture type [0..1] OR
Suture comment [0..1]
Extra haemostatic sutures required? [0..1]
Other haemostatic measures required [0..1]
Comments [0..1]
Internal iliac ligation? [0..1]
Uterine artery ligation? [0..1]
[+/-] Peritoneum closure [0..1]
Peritoneum status [0..1]
Peritoneum closure method [0..1]
Peritoneum suture type [0..1] OR
Peritoneum suture comment [0..1]
[+/-] Sheath [0..1]
Sheath status [0..1]
Sheath closure method [0..1]
Sheath suture type [0..1] OR
Peritoneum and sheath closed together? [0..1]
Comments on peritoneum or sheath [0..1]
[+/-] Fat [0..1]
Fat closure status [0..1]
Other fat closeure status [0..1]
Fat closure method [0..1] OR
Fat suture type [0..1] OR
[+/-] Skin [0..1]
Skin closure method [0..1]
Skin suture type [0..1] OR
Other skin suture type comment [0..1]
Comments on fat or skin closures [0..1]
[+/-] Hysterectomy [0..1]
Hysterectomy performed? [0..1]
Reason for hysterectomy [0..1]
[+/-] Suture removal [0..1]
Skin sutures need removing? [0..1]
Plan for removal [0..1]
[+/-] Drains [0..1]
Drains inserted? [0..1]
[+/-] Drain details (per drain) [0..*]
Drains sited [0..1]
Other drain site comment [0..1]
Type of drain [0..1]
Other comments [0..1]
Estimated blood loss [0..1]
Urine clear at end of procedure? [0..1]
[+/-] Counts [0..1]
Counts correct at end of procedure [0..1]
If not correct, action taken [0..1]
General comments [0..1]
Delivery of baby [0..*] 
Observations about delivery (v2 draft) [0..*] [+/-] Multiple births [0..1]
Fetal identification reference [0..1]
Birth order [0..1]
Outcome of Caesarian delivery [0..1]
Sex of baby [0..1]
[+/-] Delivery details [0..1]
Easy delivery? [0..1]
Failed methods attempted [0..1]
Forceps required? [0..1]
Pressure required from below? [0..1]
Date and time of delivery [0..1]
If emergency, reasons for any delay [0..1]
Other delivery details [0..1]
Cord around neck? [0..1]
True knot in cord? [0..1]
Name of paediatrician [0..1]
Other comments on delivery [0..1]
[+/-] Placenta delivery [0..1]
Was placenta delivered? [0..1]
If no, reason not removed [0..1] OR
Method of placenta delivery [0..1]
Placenta delivery comments [0..1]
Blood gases [0..*]