OB Guideline 27: Obstetrical Surgery Safety Communication

Each institution will develop guidelines for communication prior to, during, and immediately after, obstetrical surgery.^1-3 Guidelines should include specific items to be communicated by the surgical team, which may include the obstetrician, surgical assistant, scrub nurse or scrub tech, circulating nurse, and the anesthesiologist. Learners should also be included. Communication should be ongoing and may include a preoperative briefing of the surgical team in addition to the formal time-out (surgical pause) and post-operative sign out/debrief.

Briefing

The purpose of a briefing is to gather the care team together prior to moving to the operating room in order to introduce members of the team, confirm that the correct documentation is present (e.g., history and physical, consents) and to ensure that the team has a shared mental model regarding the planned procedure and the names of those participating in care. All team members should introduce themselves by name and role. The briefing should be scripted, in an interactive question-and-answer format.

Time-Out

The purpose of a time-out is to confirm correct patient and procedure immediately prior to initiation of the procedure/ surgery. A standardized, scripted, interactive time-out should be performed before each obstetrical procedure, including but not limited to: cesarean delivery, external cephalic version, peripartum hysterectomy, and dilation and evacuation. The time-out should be documented in the patient’s record. Content and timing of the time-out should be addressed in the institutional guidelines.

Items that should be considered for inclusion for communication during the briefing and the time-out:

• confirmation of patient identity from two sources;
• confirmation of need for language interpreter
• identification of trainees or learners and learning objectives
• confirmation of patient knowledge of physicians and learners participating in procedure
• confirmation of planned procedure(s) and anticipated technical challenges (e.g., history of adhesions, BMI, large fibroids)
• confirmation of patient allergies;
• confirmation of completed consent;
• confirmation of antibiotic request or administration: prophylactic, otherwise, or none needed;
• confirmation of plan for vaginal preparation
• anticipated need for pediatric providers for the birth;
• anticipated need for blood products;
• anticipated need for special or additional equipment;
• other existing pathology that should be evaluated at the time of the procedure (such as a previously noted ovarian cyst).

In an emergency, when any delay is inadvisable, the staff should cover as many of these items as possible while preparing or in the initial phases of the case.

In general, surgical marking is seldom required in obstetrical procedures. If unilaterality in approach and planned procedure exists, institutional guidelines should be followed to standardize surgical marking.

Sign Out/Debrief

The purpose of a sign out/debrief is to confirm the procedure, specimens, counts, and plans for post-operative care.

Debrief checklist items to consider, include:

1. name of procedure verified;
2. appropriate labeling of specimens confirmed;
3. estimated blood loss and fluid management;
4. team concerns discussed;
5. pain management plan;
6. sponge, needle, and instrument counts correct; and
7. equipment issues/problems addressed.

1. Obstetrical surgery includes, but may not be limited to, cesarean delivery, cerclage placement, postpartum tubal ligation, hysterectomy and dilation and evacuation (D&E).
2. Patient safety in the surgical environment. ACOG Committee Opinion No. 464. September 2010, Reaffirmed 2014. American College of Obstetricians and Gynecologists.
3. WHO Surgical Safety Checklist. www.who.int